Gender Matters: Cardiovascular Disease Risk in Women and How to Manage – Part 1
This is a summary of a presentation on women and cardiovascular disease hosted by the Federation of Medical Women of Canada Ottawa Branch on January 10, 2019 as part of their Evening Dinner & Lecture Series. A summary of both talks appeared in The Medical Post, January 31, 2019. Gender differences in cardiovascular he...nadian Healthcare Network - Physicians
Hypertensive disorders of pregnancy and future cardiovascular risk
Dr. Thais Coutinho, MD
Chief, Division of Cardiac Prevention and Rehabilitation
Chair, Canadian Women’s Heart Health Centre
University of Ottawa Heart Institute
Assistant Professor of Medicine, University of Ottawa
Heart disease kills more than five times as many women as breast cancer, although most women are not aware of this. Unfortunately, approximately 70% of the cardiovascular research focuses only on men. The main objective of this lecture is to describe the impact of hypertension disorders in pregnancy (HDP) on the future cardiovascular risk for these women. The presentation was separated into five major categories: HDP and chronic hypertension, HDP and risks for cardiovascular events, risk stratification and management after HDP, pharmacology after HDP and finally HDP and postpartum.
Dr. Coutinho began by explaining the pathophysiology of pre-eclampsia. In simple words, the arteries supplying the placenta are affected which causes a decrease in the blood flow leading to ischemia of the placenta and abnormal development of the baby. The path from pre-eclampsia to vascular disease can be summarized in 3 phases: Phase I (abnormal placentation), Phase II (maternal syndrome – endothelial dysfunction) and Phase III (after delivery – resolution or persistence of endothelial dysfunction).
HDP and chronic hypertension
Chronic hypertension (HTN) is the #1 cause of death and disability worldwide. Hypertension is particularly ominous in women, who are at greater risk of myocardial infarction, stroke, heart failure and target organ damage than men. As well, women with chronic HTN are at an increased risk of death compared to men (14% vs 11%).
Dr. Coutinho demonstrated the impact of HDP on chronic hypertension by exposing results from multiple studies. A robust meta-analysis published in 2007 showed a relative risk of 3.7, demonstrating that risk for chronic HTN is almost 4 times higher for women who had pre-eclampsia when compared to women with normotensive pregnancies. A study from 2011 found that undiagnosed hypertension or poorly treated hypertension is 3.6 times more likely to occur in women who had pre-eclampsia than in women with normotensive pregnancies. Furthermore, a study done in 2016 on 1.5 million women followed for about 10 years showed that , for women who had HDP in their 40s, the prevalence of chronic HTN was greater than 30% during the follow-up period. In addition, for young women who had HDP in their 20s, their prevalence of hypertension at the end of 10 years was higher than in women in their 40s-50s who had normotensive pregnancies, highlighting that HDP lead to early vascular aging and premature HTN diagnosis. Finally, a recent study including 200 women with severe pre-eclampsia were followed for 1 year postpartum and showed that 76% of these women were normotensive in the office, but that 23% of these apparently normotensive women actually had hypertension based on 24-hour ambulatory blood pressure monitoring. At only 1 year postpartum, 42% of all women with severe pre-eclampsia had some form of hypertension, which is an extremely high prevalence. This study may prove that we are underdiagnosing chronic HTN in women with HDP.
HDP and risks for cardiovascular events
The CHAMPS (Cardiovascular Health After Maternal Placental Syndromes) study included over 1 million women from Ontario and was published in 2005, showing that approximately 7% of women have maternal placental syndromes (gestational hypertension, pre-eclampsia, placental infarction or placental abruption), which doubled their risk for coronary artery and cerebrovascular disease, as well as tripling the risk for peripheral artery disease. And, surprisingly, the mean age at the first cardiovascular event in these women was only 38 years old. As said by Dr. Coutinho, this is a very young age to have a heart attack or a stroke!
A recent meta-analysis including 6.5 million women with pre-eclampsia showed that the highest risk of coronary heart disease is 1-10 years after pre-eclampsia. However, there is a dose-response relationship recognizing that the more severe the disease during pregnancy, the higher the risk of having a cardiovascular disease later in life. As well, recurrence of pre-eclampsia is associated with even worse cardiovascular outcomes than having only 1 pre-eclamptic pregnancy.
Finally, a large study with long follow-up (>35 years) showed that women who had pre-eclampsia during pregnancy have twice as high risk of cardiovascular mortality compared to women with normotensive pregnancies. However, women with early pre-eclampsia (≤ 34 weeks gestational age), had a 9.5-fold higher risk of cardiovascular death, with chances of surviving beyond the age 30 being only 86%.
Risk stratification and management after HDP
There is a paucity of data available on this subject. More than 1/3 of patients with HDP are unaware of future risk for cardiovascular disease. A study conducted in 2012 at one of the Harvard hospitals demonstrated that internists and obs-gyn are not fully aware of the increased risk of myocardial infarction and stroke in women who had pre-eclampsia. As well, only a small proportion of them routinely provide counseling to women about cardiovascular risk reduction. Overall, Dr. Coutinho pointed out that there is a lack of knowledge and poor communication between providers and affected women.
In postpartum cardiovascular risk management, Dr. Coutinho highlighted that the risk scores that are currently for cardiovascular risk stratification (Framingham, Reynolds, etc) are known to underestimate risk in women, especially in the younger ones. The “lifetime risk” is probably the best score for young women, but Dr. Cuutinho emphasized that none of the risk scores include the obstetrical history! While some guidelines highlight that women with HDP are at higher risk of cardiovascular disease, these guidelines do not provide detail in terms of when to screen for risk factors and how to manage them. As well, there are consensus/opinion documents from the American Society of Obstetrics and Gynecology about optimizing postpartum care, and about hypertension in pregnancy. However, these documents provide minimal clinical guidance for physicians. More awareness and research are definitely needed.
Pharmacology after HDP
Until late December 2018, no studies had addressed the role of pharmacology to decrease cardiovascular risk in women with HDP. However, a new retrospective study published in Neurology in December of 2018 including 84K women showed that while the risk of stroke after HDP is increased by about 50%, taking aspirin chronically appears to eliminate this risk. The caveat is that this was a retrospective study, therefore clinical trials of aspirin in the prevention of future cardiovascular disease after HDP are needed.
HDP: Initiatives at the Canadian Women’s Heart Health Centre
Th Canadian Women’s Heart Health Center currently has a program named “IMPROVE Post-Partum Program” as part of the CardioPrevent Program. IMPROVE stands for Identify Methods for Postpartum Reduction of Vascular Events. This program pairs women with HDP with a Health Coach for 12 months, when they have 19 contacts in total (3 face-to-face and 16 telephones calls). The program is personalized and assesses the full cardiovascular disease risk factors of the women to help them optimize their lifestyle and habits in order to maximize their cardiovascular health and decrease their risk.
To get more information on this program, please visit the following website:
As well, referral from a physician or nurse practitioner can be done by using the following form: https://cwhhc.ottawaheart.ca/sites/default/files/Postpartum/cardioprevent_referral_postpartum_2017_sept_29.pdf
• Pregnancy is the first stress test!
• HDP are common, present in about 7% of all gestations
• HDP increase the risk of chronic hypertension in the future. Unfortunately, a large proportion of these women are not diagnosed and/or suboptimally treated.
• HDP increase the chance of myocardial infarction, stroke, heart failure, and death, in a dose-response manner.
• Always obtain obstetrics history as part of the cardiovascular work-up and cardiovascular risk profile.
• There is critical need for systematic programs for referral detection and management of risk in these women.
• Lifestyle modifications need to be implemented early on in women with HDP to prevent further cardiovascular disease.
Thank you to University of Ottawa, MD students, Julie Lombardi and Sara-Michelle Gratton who provided the summaries of both talks at the January 10th event. Dr. Arnaout’s presentation, Women & Diabetes is posted in a separate blog post as Part 2.
Thank you to all who came! What an enlightening evening about an important subject for women’s health.