Lifetime Cardiovascular Disease Risk Prediction and Social Determinants of Cardiovascular Health in Women with a History of Gestational Hypertension and Preeclampsia in Kenya

Abstract

The global cardiovascular disease (CVD) burden among women is on an upward trend, adversely affecting women in low and middle-income settings (LMIC). Gestational hypertension and preeclampsia, a subset of hypertensive disorders of pregnancy, have a 2 to 6-fold increase in future cardiovascular events based on data from high-income countries. While gestational hypertension or preeclampsia may resolve post-delivery, the lingering impact of cardiovascular stress during pregnancy, vascular inflammation, endothelial dysfunction, and prevailing CVD risk factors including elevated blood pressure, dyslipidemia, hyperglycemia and increased body mass index, pose a high likelihood of experiencing future CVD events such as fatal and non-fatal coronary heart disease, stroke, peripheral vascular disease, and heart failure. While the postpartum period is an opportune window for CVD risk reduction, postpartum cardiovascular assessment, especially in LMIC like Kenya, is underutilized. Sociodemographic hardship, an adverse score of social determinants of health (SDOH), includes social, economic and environmental factors that impact cardiovascular health. While SDOH's impact on CVD risk and development is established, its influence on blood pressure changes in postpartum women with gestational hypertension or preeclampsia in Kenya is unknown. This thesis compares the lifetime CVD risk among postpartum Kenyan women with and without gestational hypertension or preeclampsia and examines the influence of SDOH on blood pressure changes. In the first aim, we evaluated the 6-month postpartum CVD risk using pooled cohort equations (PCE), comparing women with a history of gestational hypertension or preeclampsia in their most recent pregnancy versus those who had a normotensive pregnancy. We hypothesized that women with a history of gestational hypertension or preeclampsia would have a higher lifetime CVD risk. In the second aim, we explored the correlation between SDOH, blood pressure (BP) and other CVD risk factors among those with gestational hypertension or preeclampsia from 6 months to 24 months postpartum. We hypothesized that a high SDOH burden would be associated with high CVD risk factors. In the first aim, women with a history of gestational hypertension or preeclampsia had significantly higher mean predicted lifetime CVD risk scores and were twice as likely to have a high predicted lifetime CVD risk of ≥ 39% (p <0.001) compared to normotensive women. In the second aim, we observed that at 6 months postpartum, women with gestational hypertension or preeclampsia exhibited elevated cardiometabolic risk factors that included elevated BP, hypercholesterolemia and obesity. A high SDOH burden was positively correlated with non-significant high BP (p = 0.171). Linear mixed models showed non-significant trends between SDOH and BP but significant effects of age, diet and physical activity factors on systolic BP (p < 0.05). Secondary cardiometabolic risk factors had non-significant varying trends by SDOH burden. Together, these findings highlight the heightened CVD risk during the postpartum period following a pregnancy complicated by gestational hypertension or preeclampsia. Integrating cardiovascular risk assessment and stratification using PCE and SDOH in routine postpartum care in resource-limited settings, regardless of gestational hypertension or preeclampsia status, can facilitate timely interventions, enhancing the overall cardiovascular health of postpartum women.