Cardiovascular risk management after a hypertensive disorder of pregnancy.

A wareness of cardiovascular disease in women is increasing and is currently a main topic of the heart associations and foundations worldwide. Although several guidelines underscore sex differences in clinical presentation, treatment, and prognosis, almost no attention is given to a unique risk marker in women: the obstetric history. Large epidemiological studies have confirmed the association between a hypertensive disorder of pregnancy and the risk of future cardiovascular disease. Despite this, physician's awareness of a hypertensive disorder of pregnancy as a risk factor for cardiovascular disease is limited. There seems to be no structured follow-up of women after a hypertensive disorder of pregnancy, and guidelines on cardiovascular risk management after a hypertensive disorder of pregnancy are lacking. It is time to incorporate this easily identifiable risk marker into cardiovascular risk management in women. The purpose of this review is to identify current barriers and opportunities for cardiovascular risk management after a hypertensive disorder of pregnancy and to suggest a practical approach for risk management. More women die of cardiovascular disease than of any other cause. 1 During the last decade, the focus of primary prevention has widened from individuals with the highest risk and largest short-term benefit (usually older people with previous cardiovascular events) to include individuals at an earlier stage of disease to prevent target-organ damage. Young women have a low absolute risk of cardiovascular disease, and premenopausal women are in general protected. Few women <65 years of age will be considered high risk with traditional risk prediction models for cardiovascular disease, such as the Framingham risk score, the Systematic Coronary Risk Evaluation (SCORE), and the QRISK score. 2-4 Still, women have a lifetime risk of cardiovascular disease of 30% to 40% at 50 years of age. 5,6 Using a 30-year prediction model, women with multiple risk factors (unfavorable lipids, hypertension, and smoking) had a 12% predicted risk of cardiovascular disease at 25 years of age, increasing to 42% at 45 years of age. 7 The obstetric history offers a unique risk marker to identify young women at risk for future cardiovascular disease. Preeclampsia occurs in 3% to 5% of all pregnancies, 8 a figure comparable to the prevalence of diabetes mellitus at reproductive age, a well-accepted risk marker for cardiovascular disease. 9 The prevalence of any hypertensive disorder of pregnancy is up to 5% to 10% of all pregnancies and rising with the epidemic of obesity. 8 Women …