A missed opportunity? Recognizing pregnancy-associated cardiovascular risk factors.

Cardiovascular disease (CVD) is the leading cause of death in women older than 50 years. Risk factors relatedtoan increase inCVDinpostmenopausal women include increasing abdominal obesity, dyslipidemia, insulin resistance, and hypertension. A new set of risk factors added to the 2011 American Heart Association’s Effectiveness-Based Guidelines for the Prevention of Cardiovascular Disease in Women are a history of preeclampsia, gestational diabetes (GDM), or pregnancy-induced hypertension. These pregnancy-related factors highlight the unique cardiovascular and metabolic stress of pregnancy. They provide an opportunity to better estimate lifetime CVD risk as well as monitorandcontrol risk factorsaccordingly, in the years after pregnancy. Hypertensive disorders of pregnancy (HDPs) include chronic hypertension, gestational hypertension, and preeclampsia. These disorders of pregnancy have increased during the past 20 years and may be related to an increase in obesity rates and maternal age. The increased incidence of CVD risk factors mirrors the incidenceofHDPs. The National Health and Nutrition Examination Surveys conducted from 1988 to 2004 indicate increased prevalence of metabolic syndrome and its clinical correlates in US women of childbearing age. The clinical correlates of metabolic syndrome are abdominal obesity, hypertension, dyslipidemia, and impaired fasting glucose; according to the National Health and Nutrition Examination Surveys, approximately 60% of women aged 18 to 44 years have one or more of these potentially modifiable cardiometabolic risk factors. Elevated blood pressure in pregnancy and subsequent CVD risk were the subject of a large populationbased prospective study based in Northern Finland. A 1966 cohort (n = 10,314) was followed for 39.4 years, demonstrating an association between HDPs and subsequent CVD including hypertension, ischemic heart disease, ischemic stroke, thromboembolicdisease,heart failure, chronic kidney disease, diabetes mellitus, and arrhythmias. Importantly, this study was the first to demonstrate the risks associated with new-onset, isolated systolic or diastolic hypertension during pregnancyandsubsequentCVD.Approximately 17% (n = 1608) of the women in the cohort were observed to have new-onset isolated elevation in systolic or diastolic blood pressure during pregnancy, and an estimated 30% (513) of them had a cardiovascular event in their mid-60s; 3% (36) died of myocardial infarction. Preeclampsia occurs in approximately 3% of pregnancies. It is defined by onset of hypertension (Q140/90 mm Hg) and proteinuria (0.3 g for 24 hours) after 20 weeks of gestation. It abates with delivery of the placenta and is most common in the first pregnancy. Preeclampsia shares several pathophysiologic features with atherosclerosis including endothelial dysfunction, activation of the coagulation cascade, insulin resistance, and dyslipidemia (elevated low-density lipoprotein cholesterol, elevated triglyceride, and low highdensity lipoprotein cholesterol). It is more common and severe in African American women and in those with lower socioeconomic status. Bellamy and colleagues reviewed epidemiologic data from more than 2 million women, followed for a mean of 13 to 15 years, and demonstrated that preeclampsia, regardless of severity, resulted in a 2.6-fold increased risk for fatal myocardial ischemic events. Preeclampsia with a preterm delivery compared with a term delivery was associated with