Dr Emily Lau:

Hi, I'm Emily Lau. I'm a Cardiologist at Mass General Brigham and the Director of Women's Heart Health at the Brigham and Women's Hospital.

Why is it important for cardiologists to understand the relationship between pregnancy and cardiovascular-kidney-metabolic health?

Many cardiologists may not realise that pregnancy is actually an incredibly important time for both short- and long-term cardiovascular health. In terms of short-term risk, we know actually that maternal mortality and morbidity are the highest in the US among all industrialised nations and that the incidence of pregnancy-related cardiovascular complications is rising.

And this is in large part to the fact that women are entering pregnancy less healthy than they were maybe two decades ago. In fact, we showed this in our study that the burden of CKM conditions like obesity, diabetes, hypertension, hyperlipidemia, are all rising and have risen over the last two decades.

And as a consequence we're also seeing a greater incidence of pregnancy-related cardiovascular complications. Pregnancy itself is also a pretty major stress test, a pretty hemodynamic stress test on the heart. And so for patients who either have established cardiovascular disease or undiagnosed cardiovascular disease, pregnancy can actually lead to pretty acute decompensations, and morbidity and mortality related to that.

And finally, we also know that there are many pregnancy-related complications like hypertensive disorders of pregnancy and gestational diabetes that actually confer greater risk of later life cardiovascular disease also in women.

What happens during pregnancy that can impact a woman's long-term cardiovascular health?

We are now beginning to recognise that a number of reproductive risk factors that happen earlier in a woman's life influences their risk of developing heart disease later in life. In pregnancy specifically, hypertensive disorders of pregnancy like gestational hypertension, preeclampsia or eclampsia have been shown to not only increase short-term cardiovascular risk, but also long-term cardiovascular risk.

We also know that women with a history of gestational diabetes are more likely to develop cardiovascular complications later in life, and that is in part mediated by greater development of bona fide diabetes. But this really highlights the importance actually of doing a very thorough reproductive history in all of our female patients to better understand, well, what are their risk factors in addition to the traditional risk factors that we're always used to asking our patients, but what happened during their pregnancy?

Did they actually have preeclampsia? Did they have gestational diabetes? Because that actually influences one's risk for cardiovascular disease later on and may in fact modulate how we should be thinking about preventive therapies. In fact, in the new guidelines, we now codify adverse pregnancy outcomes like hypertensive disorders of pregnancy as risk-enhancing factors for the development of atherosclerotic cardiovascular disease.

And so that might actually help influence whether you might consider putting somebody on a lipid-lowering medication, for example, or in fact really being, it also should signal to providers to be very aggressive about making sure that cardiovascular health is optimised.

How should cardiologists approach risk assessment and management in women before, during, and after pregnancy?

Certainly during pregnancy, there are a number of risk scores and risk tools that can help identify what a patient's risk of developing a cardiac complication during pregnancy is. These risk scores are primarily for individuals with existing heart disease, existing structural heart disease, both acquired and congenital heart disease, so there are good tools for patients who have heart disease, who have diagnosed heart disease, but they do miss out on a large swath of women, probably the majority of women who do not have known cardiovascular disease.

But in those patients there are a number of risk scores like the CARPREG or the modified women's health organisation modified score that can help you identify whether a woman is low-, moderate- or high-risk for developing a cardiac complication. And that will help determine the degree and frequency of surveillance that you need throughout the pregnancy, may help you prioritise preventive therapies like aspirin for preeclampsia prophylaxis, and really help triage patients to help us make decisions about where we should be delivering the patient, how they might labor, for example.

Those are tools, they're imperfect, obviously, they really are restricted to people with established cardiovascular disease. So, it really does highlight a need for us to develop wide-reaching tools to be able to help risk stratify our patients, especially those who don't have an established diagnosis of heart disease.

And we know, for example, that many women may not have cardiovascular disease, but they have cardiovascular risk factors or CKM conditions like obesity, diabetes, hypertension. Those increase one's risk for developing heart disease or cardiovascular complications during pregnancy. And so, we really need to be thinking about how we might be able to identify those patients too, who might need closer monitoring, et cetera.

And then in terms of after pregnancy, as we think about cardiovascular prevention in women in general, of course, we have a number of clinical risk calculators like the pulled cohorts equation and now the prevent equations that can help give us a sense of 10-year estimated ASCVD risk for the prevent.

Now you even have 30 year risk, and not just ASCVD, you have heart failure risk and total cardiovascular disease risk. But that's really only one tool that one can use to help better stratify a woman's risk of heart disease. And they don't actually include the reproductive risk factors like adverse pregnancy outcomes.

So, what I do in my practice is I will use one of, usually the prevent equation. Give me a baseline 10 and 30-year estimated cardiovascular disease risk. I will also ask a very thorough reproductive history to better understand whether or not my patient has one of those risk-enhancing factors.

And then there's also been an advent in interest in potentially adding other biomarkers, LDL cholesterol, which is not totally codified in the prevent score, but LDL cholesterol, high sensitivity CRP and Lipoprotein(a), which is also another risk-enhancing factor.

But those biomarkers may also help further refine your risk assessment for your patients.

What are your key take-home messages for cardiologists?

I would say that pregnancy is an important life event that influences one's cardiovascular health. We need to be thinking about cardiovascular health in our patients before they become pregnant, optimising their cardiovascular health so that they can have the safest pregnancies and healthiest pregnancies.

We need to be thinking about optimising cardiovascular health during pregnancy, and then especially in that postpartum period. I think that's often where patients will fall off or will sort of become disengaged with care. And then we also need to be, for our older patients, looking backwards in time and recognising that pregnancy actually is an important life event that actually influences our cardiovascular risk later in life also.

So to me, my big takeaway to cardiologists is that pregnancy is part of our lane, it's part of our job. And we need to understand really how to optimise cardiovascular health before, through, after pregnancy and then many decades after pregnancy too.