Pub Date: Monday, Mar 29, 2021
Author: Eliza C. Miller, MD, MS
Affiliation: Department of Neurology, Division of Stroke and Cerebrovascular Disease, Columbia University
The so-called “Golden Hour” for conditions such as sepsis and acute stroke refers to a critical time window for early recognition and treatment, when we can change a patient’s clinical trajectory and prevent severe morbidity and mortality.1,2 This week, the American Heart Association/American Stroke association (AHA/ASA) released a Scientific Statement on adverse pregnancy outcomes (APOs) and cardiovascular disease prevention in women. The authors highlight the growing body of evidence showing that APOs, including preterm birth, hypertensive disorders of pregnancy, fetal growth restriction and other placental complications, provide an early glimpse into a woman’s cardiovascular risk profile. Many young women rarely (or never) seek medical attention outside of pregnancy. Thus, pregnancy and the postpartum period can be considered a “Golden Year” in a woman’s life, offering a rare opportunity for clinicians to identify young women at risk and work with them to improve their cardiovascular health trajectories.
There is now abundant, strong evidence that women who have APOs have heightened risk of cardiovascular disease.3-5 Whether the APOs themselves are to blame from the pathophysiological standpoint, or whether APOs are simply an early marker of underlying cardiovascular risk, remains unclear. Aspirin has already been shown in clinical trials to reduce the risk of preeclampsia and preterm delivery in women at higher risk for these conditions.6,7 It is possible that women who experience APOs, particularly the highest risk events such as early-onset preeclampsia, would benefit from primary preventive treatment with aspirin, statins, or other medications.8 Such strategies should be tested in clinical trials.
However, we do not need clinical trials to tell us that women with early onset chronic hypertension should be identified, told of their diagnosis, and educated about treatment strategies. For some women with hypertensive disorders of pregnancy, the blood pressure never normalizes after delivery.9 In addition, APOs are associated with the development of new hypertension as soon as two years after delivery.10 Nevertheless, many women remain unaware of their diagnosis of hypertension and go untreated for years.
The Golden Hour in acute care is easily missed. Patients do not always recognize their stroke symptoms, or know the importance of immediately activating emergency medical services. An overwhelmed clinician in a crowded emergency department can miss early warning signs of impending septic shock. The Golden Year of pregnancy is more forgiving. Women have multiple encounters with their obstetric providers throughout the pregnancy. At the time of delivery, most women will be admitted to a hospital. In particular, women who have APOs such as preeclampsia are likely to have extended encounters with the medical establishment.11 Furthermore, many women have multiple pregnancies (and often, multiple APOs), giving us repeated chances to take advantage of the Golden Year. In addition, while the Golden Hour occurs after the disease process is already well underway, the Golden Year has the potential to help avert future cardiovascular events, making interventions likely to be highly cost-effective.
Too often, we miss our chance. Too many women miss postpartum visits due to lack of insurance, childcare, or resources.12,13 Even more troubling, women with APOs have reported feeling traumatized by their childbirth-related encounters with doctors,14,15 leading them to avoid care afterwards.16,17 This holds particularly true for Black, Indigenous, and other women of color, LGBTQ+ people, non-English speakers, women with disabilities, and women with obesity.18-22 Many of these same factors are associated with an outsized risk of APOs.23-30 Thus, we miss opportunities to improve long-term cardiovascular health for women who are already suffering the consequences of implicit bias and health disparities. In fact, if women’s experiences of APOs lead them to avoid future care, our pregnancy-related encounters with women have the potential to harm women’s health trajectories.
The AHA/ASA has already called for closer monitoring and intensive risk factor modification in the postpartum period for women with APOs.31 This “fourth trimester” model of care should be implemented as a key strategy for cardiovascular risk reduction after APOs. Telehealth visits and home blood pressure monitoring are powerful tools that could be employed for this purpose. Smooth transitions from obstetric care to general primary cardiovascular care, or specialty care if needed, should be established. Rigorous qualitative research is needed to understand how we can better support women who experience APOs both during and after the event.
Broad policy initiatives have made the Golden Hour for sepsis and stroke a standard goal in acute care.32,33 It is time for similar initiatives that recognize and capitalize on the Golden Year of pregnancy, as a unique and fleeting opportunity for cardiovascular disease prevention in women.
Parikh NI, Gonzalez JM, Anderson CAM, Judd SE, Rexrode KM, Hlatky MA, Gunderson EP, Stuart JJ, Vaidya D; on behalf of the American Heart Association Council on Epidemiology and Prevention; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Cardiovascular and Stroke Nursing; and the Stroke Council. Adverse pregnancy outcomes and cardiovascular disease risk: unique opportunities for cardiovascular disease prevention in women: a scientific statement from the American Heart Association [published online ahead of print March 29, 2021]. Circulation. doi: 10.1161/CIR.0000000000000961
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- Hoffman MK, Goudar SS, Kodkany BS, Metgud M, Somannavar M, Okitawutshu J, Lokangaka A, Tshefu A, Bose CL, Mwapule A, Mwenechanya M, Chomba E, Carlo WA, Chicuy J, Figueroa L, et al. Low-dose aspirin for the prevention of preterm delivery in nulliparous women with a singleton pregnancy (ASPIRIN): a randomised, double-blind, placebo-controlled trial. The Lancet. 2020;395(10220):285–293.
- Miller EC, Boehme AK, Chung NT, Wang SS, Lacey JV, Lakshminarayan K, Zhong C, Woo D, Bello NA, Wapner R, Elkind MSV, Willey JZ. Aspirin reduces long-term stroke risk in women with prior hypertensive disorders of pregnancy. Neurology. 2019;92(4):e305–e316.
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