Malamo Countouris, MD, Cardiologist, University of Pittsburgh, talks about preeclampsia and hypertension in pregnancy and how that can lead to later heart disease.
Could you tell me what you and your colleagues were interested in this topic in particular and then I’ll ask you a little bit about the study?
COUNTOURIS: Sure, absolutely. So, we know that women who have high blood pressure in pregnancy, we use an umbrella term for this, hypertensive disorders of pregnancy that include preeclampsia and gestational hypertension are at increased risk of heart disease in later life. Even just in the 10 to 15 years after delivery, we see that these women are at increased risk of a heart attack, for a stroke, for heart failure. The idea behind our study was to really see if we could find some sort of preclinical findings of perhaps early evidence of heart disease in these women and help us sort of think about why these women go on to develop heart disease in later life.
You had mentioned that there’s an increase, can you tell me how much? Is it a significant increase? Can you give me a little just context?
COUNTOURIS: It is significant. It’s actually on par with some more traditional risk factors that we think about like having high cholesterol. So about double the risk of ischemic heart disease, like a heart attack or a stroke, and about four times the risk of developing high blood pressure.
You’re talking about pregnancy, so you’re talking about women in their 20s and 30s, possibly 40s.
COUNTOURIS: Yes.
Why is this so concerning when you’re talking about women in the age group, age range?
COUNTOURIS: I think in particular, we are finding that hypertensive disorders of pregnancy are a risk factor for early cardiovascular disease development, and I think the sort of 35 to 45 window provides us kind of a unique time point to really investigate, are there sort of early markers that we can see that might link to later cardiovascular disease? And you know, actually women with severe preeclampsia, about 40% of them have high blood pressure just one year after delivery. So, if you have more severe forms of the hypertensive disorders, that can have more serious implications even early after delivery.
For our viewers who’ve heard the term but may not be familiar, what happens when you have preeclampsia?
COUNTOURIS: Preeclampsia is when you have high blood pressure in pregnancy, plus you have some other organ involvement, most classically we think of that as proteinuria or protein excretion in the urine but it can also involve other organs. You can have low platelet levels, you can have elevated liver enzymes, heart failure along with the preeclampsia. Gestational hypertension is sort of high blood pressure alone, that develops only during pregnancy and classically then we’ll resolve after delivery. That being said, we still know that both of those, preeclampsia and gestational hypertension are linked with future heart disease.
Are there symptoms? I mean, we’re talking about women who are, you know, they’re focused on their pregnancy. They’re not even thinking about their heart health really at this point.
COUNTOURIS: I think for patients and women who are pregnant to be aware of the symptoms of preeclampsia is really important. High blood pressure alone sometimes is sort of silent. But preeclampsia oftentimes can be associated with more sudden onset of swelling, you know, lower extremity or swelling in the legs is common during pregnancy but if you see that develop more suddenly, then that can be a symptom. Headaches can be a symptom, vision changes. Sort of some of the sequelae that you may see with very high blood pressures – shortness of breath, chest and that kind of thing.
And if you’re having any of these symptoms, what are the steps?
COUNTOURIS: Definitely, you want to contact your O.B. provider. It is becoming more and more standard for women to monitor their blood pressures during pregnancy. And I think that’s one of the easiest ways for us to really identify high blood pressure early. Making sure that you have a blood pressure cuff. Ask your obstetricians if they might have a blood pressure cuff that they can give you for the pregnancy but checking blood pressure regularly. And if their blood pressure is elevated, if it’s greater than 140 over 90 during pregnancy or if you have some of these symptoms that I mentioned, then I think it’s important to contact your O.B. and ask them about next steps for testing.
Not even just waiting for that monthly visit?
COUNTOURIS: Definitely not.
When you say regularly, how often would you recommend women check?
COUNTOURIS: I would say at least weekly during the first and second trimesters. And you know, preeclampsia comes up most commonly in the third trimester. Once you reach that threshold, checking even daily is not too frequent.
Now, you said this sets them up for problems later in life, I want to talk a little bit about that. What are you seeing? How much later in life and exactly what kind of trouble or kind of heart damage could you find?
COUNTOURIS: In our study, we actually brought women back eight to 10 years after their deliveries and we did echocardiograms, so ultrasounds of the heart, and we specifically looked at the left ventricle. The left ventricle is on the left side of the heart. It’s the major pumping chamber of the heart. It’s, by nature, the most muscular. And we were curious to see if women with hypertensive disorders of pregnancy had changes in that heart structure and function. And indeed, we did find that women with hypertensive disorders of pregnancy have thicker left ventricles, so the muscle wall of the left ventricle has increased in these women in particular compared with those who did not have a hypertensive disorder of pregnancy.
About what percentage of women will develop one of these conditions during their pregnancy and what are the risk factors? You’d mentioned a 35 to 45 window, so being a slightly older mom, does that increase your risk?
COUNTOURIS: Hypertensive disorders of pregnancy are actually quite common. About 1 in 10 women or 10% of women throughout their lifetime will have a hypertensive disorder of pregnancy. The risk factors are many but being older during your pregnancy can increase your risk. Having preexisting conditions like high blood pressure or diabetes, being overweight or obese, especially women who have a body mass index greater than 30. Having chronic kidney disease is another condition as well.
Is there a takeaway I didn’t ask you that you want to make sure that people know about this study?
COUNTOURIS: I think the major takeaway is that just in the decade after delivery, we’re finding that there are structural changes in the heart for women that have preeclampsia or hypertensive disorders of pregnancy. This isn’t something that they would necessarily feel but we’re able to see it on ultrasound. In particular, the women who have the hypertensive disorders of pregnancy, who also develop hypertension or high blood pressure in that decade of time, they’re already having changes in the structure of their heart. We call that left ventricular remodeling. So, really important, I think, that we recognize that this may be part of the pathway for development of clinical heart disease. And I think for the future, we want to really investigate what we can do to modify that risk. Are there things that we can be doing that arch – changing that left ventricle remodeling, so reversing it back to normal and helping to prevent heart disease for the future.
You touched on this a little but even 10 or 20 years after pregnancy, is it too late to address those changes and those potential problems with the left ventricle?
COUNTOURIS: You know, I think that the years after delivery are the perfect time to start to address it. I think it’s under-recognized among women that high blood pressure in pregnancy is a risk factor for heart disease. Talking with your primary care physicians or even cardiologists about having that condition and then screening for risk factors for heart disease, that 5 to 10-year window is actually perfect because when we talk about prevention, we want to catch people before they’ve actually developed heart disease. I think that’s the perfect time point. If women are older, or sort of later after delivery, I think it’s never too late to discuss.
Are you able to speak at all about Julianna’s situation?
COUNTOURIS: She had preeclampsia during her first pregnancy and when I saw her, she was actually around eight years or so after her first delivery. So, this was sort of a perfect time for someone to come and see a cardiologist and talk about what we can do to maximize prevention. You know, checking for high cholesterol, checking for diabetes and then managing blood pressure is probably the most important piece in these women since they are at such an increased risk of high blood pressure. Making sure blood pressure is controlled and talking about lifestyle changes that can help reduce blood pressure.
Is she working on some of those things now?
COUNTOURIS: Yeah, absolutely. I think she may also weigh in on this too but one of the things that we’ve been working on is weight loss and making sure to have a healthy BMI is really important because it helps with high blood pressure and obviously helps for reduction of heart disease for the future.
What foods would you recommend women to stock up on to possibly help their heart health during pregnancy and what foods should they really think about avoiding to maintain a healthy heart?
COUNTOURIS: Some of this we are still investigating. During pregnancy, there’s not one clear-cut diet that will reduce your risk for preeclampsia or high blood pressure in pregnancy. That being said, if we can sort of extrapolate from what we know about hypertension in general, a low sodium or low salt diet is extremely important. Then the other recommendation would be something in line with an acronym, it’s called the DASH diet. A diet approach to stop hypertension. The hallmarks of that in addition to low salt are lots of fruits and vegetables, lean meat protein, avoiding the red meats and focusing more on fish or white meat chicken or even nonmeat protein, so legumes, nuts and tofu things like that can actually lower blood pressure by five to 10 millimeters of mercury if you adhere to it pretty strictly.
Anything else you would recommend to your patients in terms of nutrition for pregnant patients?
COUNTOURIS: I think that’s pretty much it, yeah.
Interview conducted by Ivanhoe Broadcast News.
END OF INTERVIEW
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