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Pregnancy

Interventions to Mitigate Risk of Cardiovascular Disease After Adverse Pregnancy OutcomesA Review

Educational Objective
To identify the key insights or developments described in this article

1 Credit CME

JAMA Cardiology

Published Online: October 27, 2021

Review

Article Information and Disclosures

Amanda R. Jowell, BA¹;

Amy A. Sarma, MD, MHS^2,3,4;

Martha Gulati, MD, MS⁵;

Erin D. Michos, MD, MHS^6,7;

Arthur J. Vaught, MD^8,9;

Pradeep Natarajan, MD, MMSc^2,3,10,11;

Camille E. Powe, MD^2,12;

Michael C. Honigberg, MD, MPP^2,3,4,10,11

Author Affiliations

¹Currently a medical student at Harvard Medical School, Boston, Massachusetts
²Department of Medicine, Harvard Medical School, Boston, Massachusetts
³Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston
⁴Corrigan Women’s Heart Health Program, Massachusetts General Hospital, Boston
⁵Division of Cardiology, University of Arizona, Phoenix
⁶Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland
⁷Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
⁸Division of Maternal-Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
⁹Division of Surgical Critical Care, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
¹⁰Program in Medical and Population Genetics and Cardiovascular Disease Initiative, Broad Institute of Harvard and MIT, Cambridge, Massachusetts
¹¹Cardiovascular Research Center, Massachusetts General Hospital, Boston
¹²Diabetes Unit, Endocrine Division, Department of Medicine, Massachusetts General Hospital, Boston

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Abstract

Importance A growing body of evidence suggests that adverse pregnancy outcomes (APOs), including hypertensive disorders of pregnancy, gestational diabetes (GD), preterm birth, and intrauterine growth restriction, are associated with increased risk of cardiometabolic disease and cardiovascular disease (CVD) later in life. Adverse pregnancy outcomes may therefore represent an opportunity to intervene to prevent or delay onset of CVD. The objective of this review was to summarize the current evidence for targeted postpartum interventions and strategies to reduce CVD risk in women with a history of APOs.

Observations A search of PubMed and Ovid for English-language randomized clinical trials, cohort studies, descriptive studies, and guidelines published from January 1, 2000, to April 30, 2021, was performed. Four broad categories of interventions were identified: transitional clinics, lifestyle interventions, pharmacotherapy, and patient and clinician education. Observational studies suggest that postpartum transitional clinics identify women who are at elevated risk for CVD and may aid in the transition to longitudinal primary care. Lifestyle interventions to increase physical activity and improve diet quality may help reduce the incidence of type 2 diabetes in women with prior GD; less is known about women with other prior APOs. Metformin hydrochloride may prevent development of type 2 diabetes in women with prior GD. Evidence is lacking in regard to specific pharmacotherapies after other APOs. Cardiovascular guidelines endorse using a history of APOs to refine CVD risk assessment and guide statin prescription for primary prevention in women with intermediate calculated 10-year CVD risk. Research suggests a low level of awareness of the link between APOs and CVD among both patients and clinicians.

Conclusions and Relevance These findings suggest that transitional clinics, lifestyle intervention, targeted pharmacotherapy, and clinician and patient education represent promising strategies for improving postpartum maternal cardiometabolic health in women with APOs; further research is needed to develop and rigorously evaluate these interventions. Future efforts should focus on strategies to increase maternal postpartum follow-up, improve accessibility to interventions across diverse racial and cultural groups, expand awareness of sex-specific CVD risk factors, and define evidence-based precision prevention strategies for this high-risk population.

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Article Information

Accepted for Publication: September 6, 2021.

Published Online: October 27, 2021. doi:10.1001/jamacardio.2021.4391

Correction: This article was corrected online on June 14, 2023, to correct the funding information for Dr Powe.

Corresponding Author: Michael C. Honigberg, MD, MPP, Massachusetts General Hospital, 185 Cambridge St, Mail Box CPZN 3.187, Boston, MA 02114 (mhonigberg@mgh.harvard.edu).

Author Contributions: Ms Jowell and Dr Honigberg had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Jowell, Sarma, Vaught, Natarajan, Powe, Honigberg.

Acquisition, analysis, or interpretation of data: Jowell, Gulati, Michos, Honigberg.

Drafting of the manuscript: Jowell, Vaught.

Critical revision of the manuscript for important intellectual content: Jowell, Sarma, Gulati, Michos, Natarajan, Powe, Honigberg.

Administrative, technical, or material support: Natarajan.

Supervision: Sarma, Gulati, Vaught, Honigberg.

Conflict of Interest Disclosures: Dr Sarma reported receiving grants from the National Heart, Lung, and Blood Institute (NHLBI) and a CRICO Patient Safety Award outside the submitted work. Dr Michos reported receiving personal fees from the advisory boards of Novartis International AG, Amarin Corporation, Esperion, Therapeutics Inc, and AstraZeneca outside the submitted work. Dr Natarajan reported receiving grants from Amgen Inc, Apple Inc, Boston Scientific Corporation, and AstraZeneca; personal fees from Apple Inc, Blackstone Life Sciences, Novartis International AG, Genentech/Roche, AstraZeneca, and Foresite Labs; and having a spouse who is employed by Vertex Pharmaceuticals Inc outside the submitted work. No other disclosures were reported.

Funding/Support: This study was supported by grants R01HL142711, R01HL148050, R01HL148565, and R01HL151283 from the NHLBI (Dr Natarajan); grant TNE-18CVD04 from Fondation Leducq (Dr Natarajan); a Hassenfeld Scholar Award from Massachusetts General Hospital (Dr Natarajan); grant K23DK113218 from the National Institute of Diabetes and Digestive and Kidney Diseases and the Robert Wood Johnson Foundation’s Harold Amos Medical Faculty Development Program (Dr Powe); and grant T32HL094301-07 from the NHLBI (Dr Honigberg).

Role of the Funder/Sponsor: The sponsors had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: Paul Bain, PhD, MLIS, Countway Library, Harvard Medical School, Boston, Massachusetts, assisted with the literature search without compensation.

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.