Pregnancy is the “Golden Year” for Cardiovascular Disease Prevention in Women

Last Updated: October 03, 2022

Disclosure: Dr. Miller is supported by the National Institutes of Health National Institute of Neurological Disorders and Stroke (K23NS107645, 3K23NS107645-02S1), the National Institutes of Health National Institute on Aging (R21AG069111) and the Louis V. Gerstner, Jr. Foundation (Gerstner Scholars Program). Dr. Miller received personal compensation from Finch McCranie, LLP and Argionis & Associates, LLC for expert testimony regarding maternal stroke, and personal compensation from Elsevier, Inc for editorial work on Handbook of Clinical Neurology, Vols 171 and 172 (Neurology of Pregnancy).
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


  1. Nugent KL, Coopersmith CM. Fluid Management in Sepsis—Is There a Golden Hour (or Two)?* Critical care medicine. 2017;45 N2 -(10).
  2. Saver JL, Smith EE, Fonarow GC, Reeves MJ, Zhao X, Olson DM, Schwamm LH. The “golden hour” and acute brain ischemia: presenting features and lytic therapy in >30,000 patients arriving within 60 minutes of stroke onset. Stroke. 2010;41(7):1431–1439.
  3. Wu P, Haththotuwa R, Kwok CS, Babu A, Kotronias RA, Rushton C, Zaman A, Fryer AA, Kadam U, Chew-Graham CA, Mamas MA. Preeclampsia and Future Cardiovascular Health: A Systematic Review and Meta-Analysis. Circulation. Cardiovascular quality and outcomes. 2017;10(2):e003497.
  4. Wu P, Gulati M, Kwok CS, Wong CW, Narain A, O'Brien S, Chew-Graham CA, Verma G, Kadam UT, Mamas MA. Preterm Delivery and Future Risk of Maternal Cardiovascular Disease: A Systematic Review and Meta‐Analysis. Journal of the American Heart Association. 2018;7(2):CRD42017068455–45.
  5. Lane-Cordova AD, Khan SS, Grobman WA, Greenland P, Shah SJ. Long-Term Cardiovascular Risks Associated With Adverse Pregnancy Outcomes: JACC Review Topic of the Week. Journal of the American College of Cardiology. 2019;73(16):2106–2116.
  6. Rolnik DL, Wright D, Poon LC, O’Gorman N, Syngelaki A, de Paco Matallana C, Akolekar R, Cicero S, Janga D, Singh M, Molina FS, Persico N, Jani JC, Plasencia W, Papaioannou G, et al. Aspirin versus Placebo in Pregnancies at High Risk for Preterm Preeclampsia. New England Journal of Medicine. 2017;377(7):613–622.
  7. 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.
  8. 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.
  9. Hauspurg A, Lemon LS, Quinn BA, Binstock A, Larkin J, Beigi RH, Watson AR, Simhan HN. A Postpartum Remote Hypertension Monitoring Protocol Implemented at the Hospital Level. Obstetrics & Gynecology. 2019;134(4):685–691.
  10. Haas DM, Parker CB, Marsh DJ, Grobman WA, Ehrenthal DB, Greenland P, Bairey Merz CN, Pemberton VL, Silver RM, Barnes S, McNeil RB, Cleary K, Reddy UM, Chung JH, Parry S, et al. Association of Adverse Pregnancy Outcomes With Hypertension 2 to 7 Years Postpartum. Journal of the American Heart Association. 2019;8(19):e013092.
  11. Fox A, McHugh S, Browne J, Kenny LC, Fitzgerald A, Khashan AS, Dempsey E, Fahy C, O'Neill C, Kearney PM. Estimating the Cost of Preeclampsia in the Healthcare System: Cross-Sectional Study Using Data From SCOPE Study (Screening for Pregnancy End Points). Hypertension. 2017;70(6):1243–1249.
  12. Masho SW, Cha S, Karjane N, McGee E, Charles R, Hines L, Kornstein SG. Correlates of Postpartum Visits Among Medicaid Recipients: An Analysis Using Claims Data from a Managed Care Organization. Journal of women's health. 2018;27(6):836–843.
  13. Wouk K, Morgan I, Johnson J, Tucker C, Carlson R, Berry DC, Stuebe AM. A Systematic Review of Patient-, Provider-, and Health System-Level Predictors of Postpartum Health Care Use by People of Color and Low-Income and/or Uninsured Populations in the United States. Journal of women's health. 2020.
  14. Frawley N, East C, Brennecke S. Women's experiences of preeclampsia: a prospective survey of preeclamptic women at a single tertiary centre. Journal of obstetrics and gynaecology: the journal of the Institute of Obstetrics and Gynaecology. 2020;40(1):65–69.
  15. Grekin R, O'Hara MW. Prevalence and risk factors of postpartum posttraumatic stress disorder: a meta-analysis. Clinical psychology review. 2014;34(5):389–401.
  16. Henderson J, Carson C, Redshaw M. Impact of preterm birth on maternal well-being and women's perceptions of their baby: a population-based survey. BMJ open. 2016;6(10):e012676.
  17. Attanasio L, Kozhimannil KB. Health Care Engagement and Follow-up After Perceived Discrimination in Maternity Care. Medical Care. 2017;55(9):830–833.
  18. Black KA, MacDonald I, Chambers T, Ospina MB. Postpartum Mental Health Disorders in Indigenous Women: A Systematic Review and Meta-Analysis. Journal of obstetrics and gynaecology Canada: JOGC = Journal d'obstetrique et gynecologie du Canada: JOGC. 2019;41(10):1470–1478.
  19. Wang E, Glazer KB, Sofaer S, Balbierz A, Howell EA. Racial and Ethnic Disparities in Severe Maternal Morbidity: A Qualitative Study of Women's Experiences of Peripartum Care. Women“s health issues : official publication of the Jacobs Institute of Women”s Health. 2020.
  20. Incollingo Rodriguez AC, Smieszek SM, Nippert KE, Tomiyama AJ. Pregnant and postpartum women's experiences of weight stigma in healthcare. BMC pregnancy and childbirth. 2020;20(1):499.
  21. Hall J, Hundley V, Collins B, Ireland J. Dignity and respect during pregnancy and childbirth: a survey of the experience of disabled women. BMC pregnancy and childbirth. 2018;18(1):328.
  22. Malmquist A, Jonsson L, Wikström J, Nieminen K. Minority stress adds an additional layer to fear of childbirth in lesbian and bisexual women, and transgender people. Midwifery. 2019;79:102551.
  23. Gyamfi-Bannerman C, Pandita A, Miller EC, Boehme AK, Wright JD, Siddiq Z, D'Alton ME, Friedman AM. Preeclampsia outcomes at delivery and race. The journal of maternal-fetal & neonatal medicine: the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians. 2019;131(1):1–8.
  24. Creanga AA, Bateman BT, Kuklina EV, Callaghan WM. Racial and ethnic disparities in severe maternal morbidity: a multistate analysis, 2008-2010. The American Journal of Obstetrics & Gynecology. 2014;210(5):435.e1–8.
  25. Shahul S, Tung A, Minhaj M, Nizamuddin J, Wenger J, Mahmood E, Mueller A, Shaefi S, Scavone B, Kociol RD, Talmor D, Rana S. Racial Disparities in Comorbidities, Complications, and Maternal and Fetal Outcomes in Women With Preeclampsia/eclampsia. Hypertension in pregnancy. 2015;34(4):506–515.
  26. Poorolajal J, Jenabi E. The association between body mass index and preeclampsia: a meta-analysis. The journal of maternal-fetal & neonatal medicine: the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians. 2016;29(22):3670–3676.
  27. Santos S, Voerman E, Amiano P, Barros H, Beilin LJ, Bergström A, Charles M-A, Chatzi L, Chevrier C, Chrousos GP, Corpeleijn E, Costa O, Costet N, Crozier S, Devereux G, et al. Impact of maternal body mass index and gestational weight gain on pregnancy complications: an individual participant data meta-analysis of European, North American and Australian cohorts. BJOG: an international journal of obstetrics and gynaecology. 2019;126(8):984–995.
  28. Mitra M, Clements KM, Zhang J, Iezzoni LI, Smeltzer SC, Long-Bellil LM. Maternal Characteristics, Pregnancy Complications, and Adverse Birth Outcomes Among Women With Disabilities. Medical Care. 2015;53(12):1027–1032.
  29. Sentell T, Chang A, Ahn HJ, Miyamura J. Maternal language and adverse birth outcomes in a statewide analysis. Women & health. 2016;56(3):257–280.
  30. Everett BG, Kominiarek MA, Mollborn S, Adkins DE, Hughes TL. Sexual Orientation Disparities in Pregnancy and Infant Outcomes. Matern Child Health J. 2019;23(1):72–81.
  31. Mehta LS, Warnes CA, Bradley E, Burton T, Economy K, Mehran R, Safdar B, Sharma G, Wood M, Valente AM, Volgman AS, On behalf of the American Heart Association Council on Clinical Cardiology; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Cardiovascular and Stroke Nursing; and Stroke Council. Cardiovascular Considerations in Caring for Pregnant Patients: A Scientific Statement From the American Heart Association. Circulation. 2020;141(23):1–20.
  32. Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli M, Ferrer R, Kumar A, Sevransky JE, Sprung CL, Nunnally ME, Rochwerg B, Rubenfeld GD, Angus DC, Annane D, Beale RJ, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Critical care medicine. 2017;45(3):486–552.
  33. Ormseth CH, Sheth KN, Saver JL, Fonarow GC, Schwamm LH. The American Heart Association's Get With the Guidelines (GWTG)-Stroke development and impact on stroke care. Stroke and vascular neurology. 2017;2(2):94–105.

Science News Commentaries

View All Science News Commentaries

-- The opinions expressed in this commentary are not necessarily those of the editors or of the American Heart Association --