A Time To Act: Addressing Pre-pregnancy Cardiovascular Health

Over the last decade, there has been significant research on the association on suboptimal cardiovascular health (CVH) and cardiovascular disease (CVD) related morbidity and mortality and outcomes such as heart failure and myocardial infarction. However, contemporary data and guidance on optimizing and addressing CVH metrics in certain subgroups of populations have been inadequate. Until recently, there has been little focus on how early CVH subsequently contributes to the adverse pregnancy outcomes for pregnant individuals and their offspring.^1–7 Additionally, guidance on implementation of innovative care delivery models, focused on addressing and optimizing maternal CVH are lacking. In an era where maternal mortality in the United States remains the highest amongst all developed nations, every opportunity to improve health outcomes in this patient population should be acted upon.¹

Pregnancy and the pre-conception time frame provide a unique opportunity to address not just high-risk CVD but also other risk factors and health behaviors that have been associated with an increase in maternal mortality and morbidity.^1,2 Traditional CVD risk factors including hypertension, hyperlipidemia, diabetes, overweight and obesity, physical inactivity, and smoking have all been associated with an increased risk for adverse pregnancy outcomes.⁸ Furthermore, graded associations between the burden of suboptimal health metrics and adverse pregnancy outcomes has been well demonstrated.³

Association of CVH and Adverse Pregnancy Outcomes on Birthing Individuals and their Offspring:

One important step in improving maternal CVH outcomes is to understand associations between pre-pregnancy CVH and adverse pregnancy outcomes, which are similarly on the rise.⁹ In addition to worse pregnancy outcomes, suboptimal pre-pregnancy CVH is associated with both maternal and offspring increased cardiovascular risk later in life, including premature coronary artery disease.¹⁰ Although a directly causal relationship linking early CVH with adverse pregnancy outcomes and subsequent cardiovascular disease has not been demonstrated, there are many associations that suggest improvement in early CVH will benefit both pregnancy and long-term outcomes.^3,8,11

The discussion continues with potential mechanisms linking pre-pregnancy CVH, adverse pregnancy outcomes, and subsequent CVD for the birthing individual and child(ren). Although studies of total pre-pregnancy CVH risk factors and downstream offspring effects are lacking, type 2 diabetes mellitus and elevated body mass index have specifically been associated with premature coronary artery disease in the offspring.^9,12 Epigenetic modification leading to different gene expression in both embryonic and placental tissue may explain the increase in adverse pregnancy outcomes and offspring CVH.¹³ Further investigation is needed to elucidate the entirety of underlying mechanisms.

Understanding the Pregnancy Related Critical Time Frame Windows:

CVD is the leading cause of death during pregnancy and the postpartum period, and special focus on the determinants of early CVH is warranted to help impact these statistics.^1,14 Pregnancy-related appointments are often an individual's first notable engagement with health care as an adult.¹⁵ While it is critical to counsel and optimize CVH during pregnancy, the data presented in this American Heart Association (AHA) Scientific Statement by Khan et al. bring light to this important topic and call for taking CVH monitoring and management one step further: reaching those in the pre-pregnancy period.^3,8 In addition, because the mechanisms underlying both adverse pregnancy outcomes and long-term cardiovascular disease are felt to begin far before pregnancy, interventions will have limited impact unless they can be implemented earlier in life.⁵

In this statement, Khan et al. bring focused attention to the pre-pregnancy period as a critical time for optimization of CVH and provide expert recommendations for cardiovascular risk optimization in individuals during the pre-conception or inter-pregnancy period using the most up to date preclinical, epidemiological, and clinical trial evidence available.¹¹ Studies have consistently shown that individuals with a history of adverse pregnancy outcomes (including pregnancy loss, preterm birth, small for gestational age infant, gestational diabetes, gestational hypertension, and preeclampsia) have increased cardiovascular risk later in life, leading to the use of said history in risk stratification guidelines.^11,16 Identifying this risk at a relatively early stage of life can then allow for decades of CVD prevention strategies. The postpartum period should be considered an opportunity to focus on lifestyle choices that optimize cardiovascular health, including weight management, smoking cessation, physical activity assessment, and nutritional counseling, particularly among those with pregnancy complications associated with increased CVD risk.

Defining CVH as it relates to the Pregnancy Windows:

The first step in addressing CVH in the pre-pregnancy period is to adequately define it. Recently, the AHA Presidential Advisory focused on focused on updating the definition of CVH from the previous AHA's construct of CVH, originating in 2010 of "Life's Simple 7" (incorporating diet, physical activity, nicotine exposure, body mass index, blood lipids, blood glucose, and blood pressure) to "Life's Essential 8^TM" (with the addition of sleep health), and exploring the prevalence of suboptimal CVH in reproductive-aged individuals.^17,18 Wide ranges of CVH are described in this population, with overall impressively low estimates of reproductive-aged adults having ideal levels of at least 5 of 7 metrics of CVH and with glaring disparities present in minorities and those with lower socioeconomic status.^7,19

Concerning trends in the data on pre-pregnancy CVH include low percentages of individuals having awareness of their modifiable risk factors and a decline in overall CVH in all subgroups from 2011 to 2019.⁶ These points suggest ample opportunity for individual and community-wide education on the importance of CVH with an emphasis on promoting optimal health practices even in childhood and/or adolescence. The authors highlight the multidisciplinary approach needed to achieve these goals, including providers from pediatricians to obstetricians, cardiologists, and internists.²⁰

Recommendations on Specific Interventions to Optimize CVH:

While both the AHA and the American College of Obstetricians and Gynecologists (ACOG) recognize the importance of addressing and optimizing CVH of birthing individuals, while targeting the pre-pregnancy time frame, there is not much evidence-based data on what specific interventions and for what duration would yield positive results in not only reduction of adverse pregnancy outcomes and maternal morbidity and mortality, but also improving long-term outcomes in the offspring.

In order to make policy-level interventions, designing clinical trials that enroll diverse participants, with focus on culturally competent care and innovative care delivery models that aim to address some structural and social drivers of suboptimal CVH are necessary. These need to be intentional with an aim to bring more equitable healthcare to all reproductive-aged individuals and hopefully help close the gaps in pregnancy-related and long-term health. These suggestions are in alignment with a policy statement from the AHA regarding efforts needed to address racial and ethnic disparities in maternal health, reduce inequities in care, and alleviate morbidity and mortality.¹

Recently, the Chronic Hypertension in Pregnancy (CHAP) trial focused on addressing and optimizing mild to moderate hypertension during pregnancy; it showed that targeting a lower blood pressure threshold of less than 140/90 mmHg in pregnancy resulted in reduction of adverse pregnancy outcomes such as preeclampsia and preterm birth.²¹ Focusing on multiple risk factors and behaviors with and without pharmacotherapies are needed in the pre-pregnancy time frame. Testing innovative clinical trial designs such as financial incentives for smoking cessation during the pre-pregnancy, pregnancy, and postpartum time frame can be tested with a combination of multifactor interventions to achieve equitable health care.²²

The proposed clinical trials would include utilization of community resources to not only bring awareness of the importance of pre-pregnancy CVH but to also implement strategies for screening, treatment, and monitoring of identified markers of suboptimal CVH. Potential leverage of smart devices and digital interventions to capture a greater proportion of the at-risk population is mentioned as a unique strategy leveraging tools that young adults are often very familiar with to promote wellness.²³ If studied, such interventions would be compared to standard of care for the pre-pregnant population. The outcomes of subsequent pregnancies would then be followed and compared between the groups.

Selecting and Implementing Best Practices that Reduce Health Disparities and Improve CVH:

In order for maternal health to be equitable, the disparities found in CVH, especially for groups that have been racially, ethnically, or socioeconomically marginalized need to be addressed. , There are several non-medical factors that influence health disparities such as housing, food insecurity, and structural racism,.²⁴ Herein lies the biggest opportunity-- to design and implement clinical interventions that focus on evidence-based practices with community engagement to leverage adherence and follow-up. Bringing together practices that bridge the digital divide and focus on culturally sensitive care delivery, especially in rural and resource limited areas, are vital towards achieving equitable maternal care.

In conclusion, the authors should be congratulated on synthesizing a thorough, multi-pronged approach for the need for addressing and optimizing CVH among birthing individuals. This AHA Scientific Statement begins a broader discussion on implementation of strategies to optimize CVH. It highlights the considerable opportunity to affect long-term health trajectory by targeting individuals early in life before pregnancy, a population in which suboptimal CVH is already prevalent. It additionally reviews the foundational determinants of cardiovascular health and how different targeted interventions and structural policies can be designed to implement beneficial change with emphasis on the need for future clinical trials. Above all, it refocuses on the importance of the pre-pregnancy period as a critical time frame where intergenerational impact can be made by optimizing CVH. It calls on us to approach this work with collaboration, authenticity, and renewed vigor towards making a lasting impact in the lives of mothers and their children.