>> GOOD AFTERNOON.
MY NAME IS DR. CANDICE PRICE,
AND I AM A PROGRAM DIRECTOR AT
THE NATIONAL HEART, LUNG AND
BLOOD INSTITUTE AT NIH.
ON BEHALF OF THE NHLBI OBESITY
WORKING GROUP, I'M EXCITED TO
SERVE AS THE MODERATOR FOR THIS
18TH OBESITY, NUTRITION AND
PHYSICAL ACTIVITY SEMINAR.
PAST PRESENTATIONS HAVE
HIGHLIGHTED A VARIETY OF TOPICS
SUCH AS TECHNOLOGY ASSISTED INTD
VENGSES FOR WEIGHT MANAGEMENT,
FOOD INSECURITY AND COVID-19,
THE ROLE OF TEACHING KITCHENS IN
ADDRESSING NUTRITION
DISPARITIES, HOW TO IMPROVE FOOD
ACCESS AND OBESITY IN BALTIMORE,
THE RELATIONSHIP BETWEEN BODY
WEIGHT, AND CARDIOVASCULAR RISK
AMONG SOUTH ASIAN AMERICANS AND
MOST RECENTLY, DIETARY
BIOMARKERS TO IDENTIFY THE
CARDIOPROTECTIVE MECHANISMS OF
THE DASH DIE E TODAY'S
PRESENTATION BY DR. SADIYA KHAN
IS ENTITLED CARDIOVASCULAR
HEALTH IN THE PERIPARTUM PERIOD,
DRIVERS AND DETERMINANTS.
BEFORE WE START I WANT TO REVIEW
A FEW HOUSEKEEPING ITEMS.
THROUGHOUT THE PRESENTATION AND
Q & A DISCUSSION, PLEASE SEND
ANY QUESTIONS TO THE EMAIL
ADDRESS LISTED ON THE SLIDES.
ONPA@MAIL.NIH.GOV.
OR CLICK ON THE LIVE FEEDBACK AT
THE BOTTOM OF THE VIDEOCAST
SCREEN TO SUBMIT A QUESTION OR
COMMENT.
NOW LET'S INTRODUCE OUR SPEAKER.
DR. SADIYA KHAN IS THE PROFESSOR
OF CARDIOVASCULAR EPIDEMIOLOGY
AND TENURED ASSOCIATE PROFESSOR
OF MEDICINE AND PREVENTIVE
MEDICINE AND DIRECTOR OF THE
CENTER OF POPULATION SCIENCE AND
AGING IN THE LONGEVITY
INSTITUTE.
AND SHE IS A PREVENTIVE
CARDIOLOGIST AT THE NORTD
WESTERN UNIVERSITY FEINBERG
SCHOOL OF MEDICINE.
DR. KHAN'S CLINICAL EXPERTISE
AND RESEARCH FOCUS ON THE
EPIDEMIOLOGY, PREDICTION AND
GENETICS OF CARDIOVASCULAR
DISEASE WITH A FOCUS ON
PREGNANCY-SPECIFIC RISK FACTORS.
DR. KHAN'S RESEARCH EFFORTS ARE
SUPPORTED BY THE MULTIPLE GRANTS
FROM THE NATIONAL INSTITUTES OF
HEALTH AND THE AMERICAN HEART
ASSOCIATION.
DR. KHAN HAS PUBLISHED OVER 300
PEER REVIEWED SCIENTIFIC
RESEARCH PUBLICATIONS IN LEADING
MEDICAL JOURNALS AND HAS AN H
INDEX OF 41 AS JANUARY OF 2024.
HER ORIGINAL SCIENCE HAS BEEN
HIGHLIGHTED BY THE AMERICAN
HEART ASSOCIATION AS AMONG THE
TOP ADVANCES IN HEART DISEASE
AND STROKE RESEARCH FOR FOUR
CONSECUTIVE YEARS FROM 2020 TO
2023.
WELCOME, DR. KHAN.
>> THANK YOU SO MUCH, DR. PRICE,
FOR THAT KIND INTRODUCTION AND
FOR THE OPPORTUNITY TO --
YOURSELF AND THE ORGANIZERS TO
PRESENT TODAY.
I HAVE NO RELATIONSHIPS WITH
INDUSTRY AND FUNDING AS NOTED.
SO I WANTED TO START WITH A CASE
PRESENTATION TO SET THE STAGE OF
WHAT WE'RE REALLY TALKING ABOUT
IN TERMS OF CARDIOVASCULAR
HEALTH IN THE PERIPARTUM PERIOD,
AND HOW WE DEFINE IT AND THINK
ABOUT IT.
THIS WAS A PATIENT THAT I SAW A
COUPLE OF YEARS AGO WHO'S 27,
HAD HAD AN UNCOMPLICATED
DELIVERY, AND PRESENTED TO THE
HOSPITAL FIVE DAYS POSTPARTUM
WITH ACUTE SHORTNESS OF BREATH.
HER HEART RATE WAS 90, SHE WAS
HYPERTENSIVE, SHE HAD ELEVATED
JUGULAR VENOUS PRESSURE AND
CHEST X-RAY SHOWN HERE THAT
DEMONSTRATED ACUTE VOLUME
OVERLOAD SO CONSISTENT WITH
ACUTE HEART FAILURE
EXACERBATION.
HER BIOMARKERS WERE CHECKED.
ELEVATED AT 1100 AND TROPONIN
ELEVATED AT 2.5.
WE OBTAINED AN ECHOCARDIOGRAM
THAT DEMONSTRATED OVERALL
PRESERVED EJECTION FRACTION
GIVEN OUR CONCERN FOR PERIPARTUM
CARDIOMYOPATHY BUT THERE WAS A
BIT OF INFRALATERAL HIGH
COKINESIS, OVERALL A PICTURE
CONSISTENT WITH POSTPARTUM
PRE-ECLAMPSIA THIS REALLY LED TO
TWO KEY QUESTIONS THAT BY THE
END OF THIS PRESENTATION,
HOPEFULLY WE'LL BE ABLE TO
ADDRESS.
FIRST, WHAT SHOULD WE COUNSEL
THIS PATIENT ON HER SHORT TERM
AND LONG TERM RISK OF
CARDIOVASCULAR DISEASE, AND TO
FOLLOW THAT UP, WHAT EVIDENCE
HAD BEEN BASED STRATEGIES EXIST
TO REDUCE CARD JOE VASCULAR
DISEASE IN THE PERIPARTUM PERIOD
AND WE'LL COVER THESE WITH SOME
KEY OBJECTIVES IN THE NEXT
SLIDE.
SO HOW DO HE WITHEST WE ANSWER R
AND MANY MORE LIKE LER?
LET'S THINK IN THREE STEPS OVER
THE NEXT 40 MINUTES OR SO.
FIRST, REALLY TRYING TO CLARIFY
WHAT IS THE PERIPARTUM PERIOD
AND WHY IS IT CRITICAL FOR
CARDIOVASCULAR DISEASE RISK IN
BIRTHING INDIVIDUALS?
NEXT, WE'LL DESCRIBE THE
EPIDEMIOLOGY OF ADVERSE
PREGNANCY OUTCOMES AND LOOK TO
SOME OF THE DRIVERS OF THESE
TRENDS.
AND THIRD, DISCUSS THE RATIONALE
FOR CARDIOVASCULAR HEALTH
PROMOTION IN IDENTIFYING
OPPORTUNITIES TO INTERVENE IN
THE PERIPARTUM PERIOD.
SO LET'S GET STARTED WITH THE
PERIPARTUM PERIOD WITHIN THE
CONSTRUCT OF A LIFE COURSE
APPROACH.
IF WE THINK ABOUT THE OVERALL
FEMALE LIFE COURSE AND WE GO TO
THE NEXT SLIDE, WE'LL ZERO IN ON
THE REPRODUCTIVE LIFE COURSE.
IF WE ADVANCE ONE FURTHER, WE'LL
THINK ABOUT THIS ENTIRE PERIOD
AS BEGINNING IN MENARCHE AND
ENDING IN MENOPAUSE IN WHICH AN
INDIVIDUAL WHO IS
PREGNANCY-CAPABLE MAY HAVE ONE
OR MORE PREGNANCIES DURING THIS
TIME PERIOD.
THIS COLLECTIVELY COULD BE
THOUGHT OF AS THE PREPREGNANCY,
PREGNANCY AND POSTPARTUM PERIOD,
WHICH TOGETHER IN AGGREGATE
REPRESENT THE PERIPARTUM PERIOD.
WHICH IS THE FOCUS OF THIS
DISCUSSION.
AS WE THINK ABOUT THIS, LET'S
TAKE THE RIGHT SIDE OF THIS
FIGURE FIRST AND TALK MORE ABOUT
PREGNANCY AND POSTPARTUM WHERE
THERE'S A LOT MORE DATA AND
AWARENESS AROUND ADVERSE
PREGNANCY OUTCOMES IN
CARDIOVASCULAR DISEASE RISK.
SO THAT SHORT TERM PERIOD WHERE
MATERNAL MORBIDITY AND MORTALITY
MAY BE PRESENT, INCLUDING ICU
ADMISSIONS, MORBIDITY,
MORTALITY, ADVERSE PREGNANCY
OUTCOMES, AND HOW IT AFFECT
LONG-TERM MORBIDITY AND
MORTALITY.
IF WE THINK ABOUT PREGNANCY AS A
STRESS TEST, AS IT'S BEEN
COMMONLY CALLED, WE HAVE TO
FIRST UNDERSTAND THAT PREGNANCY
IN AND OF ITSELF LEADS TO MANY
PHYSIOLOGIC VASCULAR AND
METABOLIC CHANGES THAT ARE
APPROPRIATE ADAPTATIONS TO
ACCOUNT FOR THE GROWING FETUS.
UNFORTUNATELY, WHEN THOSE
ADAPTATIONS RESULT IN
PATHOPHYSIOLOGIC CONDITIONS, OR
ADVERSE PREGNANCY OUTCOMES,
WHICH CAN INCLUDE HYPERTENSIVE
DISORDERS OF PREGNANCY OR HDP,
GESTATIONAL DIABETES OR GDM,
PRETERM BIRTH OR PTB HERE OR
SMALL FOR GESTATIONAL AGE IS
WHEN WE SEE THE SIGNAL MOVING ON
TO CLINICAL CARDIOVASCULAR
DISEASE.
ONE OF THE LARGEST AND BEST
STUDIES IN THE LAST SEVERAL
YEARS THAT HAS LOOKED AT THE
ASSOCIATION OF ADVERSE PREGNANCY
OUTCOMES AND LIFETIME RISK OF
CARDIOVASCULAR DISEASE IS SHOWN
HERE.
THIS STUDY THAT INCLUDED OVER
2 MILLION SWEDISH INDIVIDUALS
WHO HAD HAD PREGNANCIES BETWEEN
1970 TO 2000 WERE FOLLOWED FOR A
MEDIAN OF AT LEAST 25 YEARS WITH
A MAXIMUM OF 46 YEARS AT AGE 27
AT FIRST DELIVERY, WERE THEN
EVALUATED FOR THEIR RISK OF
ISCHEMIC HEART DISEASE.
AS YOU CAN SEE IN THIS FIGURE,
THE RISK ASSOCIATED WITH EACH
APO IS INCREASED FOR THE RISK OF
CVD.
NOW WE SEE DIFFERENT PATTERNS
ACROSS ADVERSE PREGNANCY
OUTCOMES WITH SOME OF THE
HIGHEST RISK RELATED TO
PREECLAMPSIA, BUT CONSISTENT
PATTERNS THROUGHOUT.
ONE OF THE THINGS THAT WAS
REALLY INTERESTING ABOUT THIS
ANALYSIS WAS THAT THEY ALSO
LOOKED AT THE INDIVIDUALS WHO
HAD MULTIPLE ADVERSE PREGNANCY
OUTCOMES AND DEMONSTRATED THIS
ADDITIVE EFFECT, SO IF YOU HAD
PRETERM AND PREECLAMPSIA OR
PRETERM AND GESTATIONAL
DIABETES, YOU HAD AN EVEN HIGHER
RISK OF ISCHEMIC HEART DISEASE
IN FOLLOW-UP AND WHAT'S EVEN
MORE IMPORTANT IS THAT ABOUT A
THIRD OF PEOPLE HAD AT LEAST ONE
ADVERSE PREGNANCY OUT COME, SO
THIS IS A PREVALENT COMPLICATION
THAT IS ASSOCIATED WITH UP TO A
TWOFOLD RISK OF CARDIOVASCULAR
DISEASE ACROSS THE LIFE COURSE.
SO IF WE WANT TO THINK ABOUT
THAT STRUCTURE OF ADVERSE
PREGNANCY OUT COME GOING TO
CARDIOVASCULAR DISEASE, I THINK
IT'S HELPFUL TO THINK ABOUT THE
PATHWAYS THROUGH WHICH THIS MAY
OCCUR, WHERE WE HAVE DATA AND
WHERE WE MAY NEED MORE DATA TO
UNDERSTAND WHERE WE COULD MODIFY
AND TARGET TO REALLY OPTIMIZE
PREVENTION.
SO LET'S FIRST START WITH
TRADITIONAL CARDIOVASCULAR
DISEASE RISK FACTORS.
DATA FROM THE NURSES HEALTH
2 STUDY ARE AMONG SOME OF THE
LARGEST SAMPLE WHERE WE HAVE
INDIVIDUALS WHO ARE FOLLOWED
FROM THEIR FIRST BIRTH TO
INCIDENCE OF CARDIOVASCULAR
DISEASE OVER A FOLLOW-UP OF MORE
THAN 40 YEARS.
SHOWN IN THIS TABLE IS THE
PROPORTION MEDIATED FOR
TRADITIONAL RISK FACTORS AFTER
AN INCIDENT HYPERTENSIVE
DISORDER OF PREGNANCY,
SPECIFICALLY HYPERTENSION,
HYPERLIPIDEMIA, DIABETES, AND
CHANGE IN BMI.
WHAT'S REALLY STRIKING IS 84% OF
THE ASSOCIATION BETWEEN
GESTATIONAL HYPERTENSION AND 57%
OF THE ASSOCIATION BETWEEN
PREECLAMPSIA AND FOLLOW-UP CVD
IS MEDIATED BY THESE TRADITIONAL
RISK FACTORS, SO TARGETS THAT WE
COMMONLY THINK ABOUT AFTER
HYPERTENSIVE DISORDERS OF
PREGNANCY MEDIATE THE MAJORITY
OF THE RISK FOR CARDIOVASCULAR
DISEASE AND HIGHLIGHT KEY
TARGETS ONCE SOMEONE HAS BEEN
IDENTIFIED WITH ELEVATED BLOOD
PRESSURE DURING PREGNANCY.
NOW WHAT'S IMPORTANT IS THAT
THESE ARE IMPORTANT FACTORS OR
TARGETS WHETHER OR NOT SOMEONE
GOES ON TO HAVE CHRONIC
HYPERTENSION, TO JUST HAVING
ELEVATED BLOOD PRESSURE IN
PREGNANCY ITSELF THAT IS
ASSOCIATED WITH FUTURE
CARDIOVASCULAR DISEASE RISK WHEN
DEFINED AS HYPERTENSIVE DISORDER
OF PREGNANCY.
THE NEXT PATHWAY THAT WE'LL TALK
ABOUT IS ABNORMAL CARDIAC
MECHANICS.
WE ALSO KNOW THAT WHEN WE THINK
ABOUT CARDIOVASCULAR DISEASE
BROADLY, HEART FAILURE CAN BE A
COMPLICATION FOLLOWING ADVERSE
PREGNANCY OUTCOMES.
WHILE WE HAVE LESS DATA HERE,
THIS IS A REALLY INTERESTING
SINGLE CENTER STUDY THAT LOOKED
AT ABOUT 130 WOMEN WHO WERE 8 TO
10 YEARS AFTER DELIVERY, WHO HAD
EXPERIENCED A HYPERTENSIVE
DISORDER OF PREGNANCY, AND
EXAMINED ECHO CARDIOGRAPHIC
EVIDENCE OF SEPTAL WALL
THICKNESS, LV WALL REMODELING
AND MITRAL INFLOW TO LOOK AT
PATTERNS OF ADVERSE CARDIAC
REMODELING.
NOW IMPORTANTLY, OF THEIR
SAMPLE, 23% HAD HYPERTENSIVE
DISORDERS OF PREGNANCY AND A
MUCH GREATER PROPORTION OF
INDIVIDUALS, 63% VERSUS 26%, HAD
HYPERTENSION POST-DELIVERY WHO
HAD HAD HYPERTENSIVE DISORDERS.
SO THERE WAS AN ADDITIVE EFFECT
WHERE PEOPLE WHO HAD HAD
HYPERTENSIVE DISORDERS OF
PREGNANCY AND HYPERTENSION HAD
THE MOST ADVERSE REMODELING IN
THEIR LEFT VENTRICLE.
ONE OF THE THINGS THAT THIS
STUDY RELY HIGHLIGHTED IS THAT
THESE ADVERSE CHANGES THAT WERE
OBSERVED 8 TO 10 YEARS AFTER
PREGNANCY MAY HAVE BEEN
MANIFESTATIONS OF
PATHOPHYSIOLOGIC RESPONSES
RELATED TO PREGNANCY ITSELF,
ESPECIALLY AMONG THOSE WHO HAD
HYPERTENSIVE DISORDERS.
THIS DIAGRAM HIGHLIGHTS THE
IMPORTANCE OF THE LEFT
VENTRICLE'S ADAPTATION TO
PREGNANCY THAT MAY ACTUALLY BE
INFLUENCED BY PRE-EXISTING
CARDIOVASCULAR DISEASE ORIS
BEING.
AND WE'LL TALK A LITTLE BIT MORE
ABOUT THIS IN THE FOLLOWING
SLIDES, BUT THE IDEA THAT
POTENTIALLY SOME OF THE ADVERSE
LV REMODELING MAY HAVE ALREADY
BEEN PRESENT BEFORE THE
PREGNANCY IS A QUESTION THAT
REMAINS UNANSWERED.
SO LET'S TALK ABOUT THE
MECHANISM AND PATHWAY TO@THROW
SCLEROSIS OR HEART DISEASE THAT
IS SUBCLINICAL@THROW SCLEROSIS.
ONE OF THE LARGEST STUDIES THAT
WAS RECENTLY PUBLISHED COMES
FROM THE SWEDISH CARDIOPULMONARY
BIOIMAGE STUDY.
THIS STUDY HAD ABOUT 10,000
INDIVIDUALS WHO WERE 50 TO 65
YEARS WHO HAD HAD A PRIOR BIRTH
WITHIN THE SWEDISH SYSTEM.
ABOUT 19% HAD AN ADVERSE
PREGNANCY OUT COME AND THEN WERE
EXAMINED WITH A CORONARY CTA.
THE INNOVATIVE PIECE ABOUT THIS
STUDY IS THAT THEY LOOKED NOT
JUST AT CORONARY CALCIUM, BUT
ALSO AT NON-CALCIFIED PLAQUE
WITH CTA.
PARTICULARLY AMONG YOUNG WOMEN,
BEFORE ANY CALCIFIED PLAQUE IS
PRESENT, ANY CORONARY
ATHEROSCLEROSIS WAS PRESENT AND
THAT'S SPECIFICALLY WHAT THEY
SAW.
SPECIFICALLY AMONG INDIVIDUALS
WHO HAD ADVERSE PREGNANCY OUT
COME, 32% HAD ANY.
IF WE LOOK ACROSS THE VARIOUS
OUTCOMES THAT WERE OBSERVED, ANY
STENOSIS, ANY CALCIFIED PLAQUE
OR SCORE GREATER THAN 100, WE
SEE A CONSISTENT PATTERN OF
HIGHER BURDEN OF
CORONARY@SCLEROSIS OR
SUBCLINICAL AMONG THOSE WHO
EXPERIENCE AN ADVERSE PREGNANCY
OUT COME.
SO IF WE THOUGHT ABOUT THE
DIFFERENT PATHWAYS FROM
SUBCLINICAL CVD TO CLINICAL CVD,
WE HAVE TO ALSO ASK ABOUT WHAT
ARE THE ANTECEDENTS TO BOTH
ADVERSE PREGNANCY OUTCOMES AND
CVD THAT MAY HELP US IDENTIFY
EARLIER PREVENTION STRATEGIES.
IF WE THINK ABOUT THE SHARED
ANTECEDENT PATHWAYS, THERE ARE
TRADITIONAL RISK FACTORS LIKE
OBESITY, SEDENTARY BEHAVIOR,
POOR QUALITY DIET, PRE-EXISTING
HYPERTENSION, HYPERLIPIDEMIA OR
DIABETES, AS WELL AS PREGNANCY
OR RELATED RISK FACTORS UNIQUE
OH A BIRTHING INDIVIDUAL THAT
MAY INCLUDE VASCULAR AND
PLACENTAL DYSFUNCTION OR GENETIC
PREDISPOSITION TO ADVERSE
PREGNANCY OUTCOMES THAT LEAD TO
THIS PATH OF CVD.
BUT ONE OF THE KEY QUESTIONS
THAT REMAINS UNANSWERED IS
WHETHER OR NOT THE ADVERSE
PREGNANCY OUT COME ITSELF IS A
MARKER OR MEDIATOR OF FUTURE
CARDIOVASCULAR DISEASE RISK.
THIS SCHEMATIC ORIGINALLY
PUBLISHED OVER 20 YEARS
HIGHLIGHTS TWO DIFFERENT
TRAJECTORIES IN A BIRTHING
INDIVIDUAL.
ONE BY WHICH THE INDIVIDUAL HAS
TWO PREGNANCIES WITH AN ADVERSE
PREGNANCY OUTCOME, AND ONE BY
WHICH AN INDIVIDUAL HAS A
HEALTHY PREGNANCY.
YOU CAN SEE THE QUESTION HERE IS
THAT WHETHER OR NOT THESE TWO
INDIVIDUALS MEET THE THRESHOLD
FOR DEVELOPING VASCULAR RISK,
WHETHER THAT'S CARDIOVASCULAR
DISEASE OR HYPERTENSION, REALLY
DEPENDS ON THEIR STARTING POINT
AS WELL AS THE INJURY RELATED TO
PREGNANCY.
SO THE FUNDAMENTAL QUESTION
REMAINS, IS AN INDIVIDUAL WHO
HAS AN ADVERSE PREGNANCY OUT
COME REALLY UNMASKED IN THIS
LATENT RISK THAT ALREADY EXISTED
AND THEY CONTINUE ON THEIR
TRAJECTORY THEY WERE ALREADY ON
OR IS THERE SOMETHING ABOUT THE
ADVERSE PREGNANCY OUT COME THAT
ALTERS THEIR TRAJECTORY AND
LEADS THEM INTO A HIGHER RISK
CATEGORY?
SO SHOWN HERE IN A CAUSAL
STRUCTURE DIAGRAM, WE REALLY
WANTED TO ASK THIS QUESTION OF
IF ADVERSE PREGNANCY OUTCOMES
ARE A MARKER OR MEDIATOR BASED
ON WHERE SOMEONE BEGINS THEIR
PREPREGNANCY CARDIOMETABOLIC
HEALTH, WHAT THEIR
CARDIOMETABOLIC HEALTH MAY BE
AFTER PREGNANCY, AND WHAT THAT
MEANS FOR THEIR RISK FOR
CARDIOVASCULAR DISEASE, GIVEN
THAT EACH OF THESE INDEPENDENT
PATHWAYS MAY BE LEADING TO
HIGHER CARDIOVASCULAR DISEASE
RISK.
SAID ANOTHER WAY, THIS ANALOGY
OF THIS PICTURE SHOWN HERE ARE
ADVERSE PREGNANCY OUTCOMES
REALLY THE SMOKE DETECTOR
HIGHLIGHTING THE RISK THAT
ALREADY EXISTS WHEN THERE'S A
FIRE IN THE HOUSE.
SO HOW CAN WE START TO
UNDERSTAND THIS?
IN WORK FUNDED BY THE NHLBI IN
THE NEW MOM TO BE HEART HEALTH
STUDY, WHICH IS A COHORT OF
INDIVIDUALS RECRUITED IN THE
BEGINNING OF THEIR FIRST
PREGNANCY, SO WE HAD EARLY
MEASURES OF BMI EARLY IN THE
FIRST TRIMESTER, AND WERE THEN
FOLLOWED DURING THIS PREGNANCY
AND NOW HAVE BEEN FOLLOWED FOR
ABOUT 10 YEARS POSTPARTUM.
AT 2 TO 7 YEARS DURING FOLLOW-UP
POSTPARTUM RISK FACTORS WERE
MEASURED AND ALLOWED US TO
STRUCTURE OUR QUESTION OF
INTEREST WITH THIS SHOWN HERE,
PREPREGNANCY OR EARLY PREGNANCY
BMI ASSOCIATE WITH ADVERSE
PREGNANCY OUTCOMES AS WELL AS
POSTPARTUM CARDIOVASCULAR
DISEASE RISK FACTORS, AND WHAT
PROPORTION OF THAT IS MEDIATED
IF ANY BY ADVERSE PREGNANCY
OUTCOMES?
SO IF WE'LL BREAK DOWN THE
EFFECT OR ASSOCIATIONS WE'LL
LOOK AT THE TOTAL EFFECTIVENESS
ANALYSIS LOOKING AT THE
PREPREGNANCY BMI AND POSTPARTUM
CVD RIS FACTORS.
WE BROKE THAT DOWN INTO THE
DIRECT AND INDIRECT EFFECT TO
GET AT THE PROPORTION MEDIATED.
IF WE LOOK HERE AT THE TOTAL
EFFECT, THE UNADJUSTED AND
ADJUSTED BETA COEFFICIENT
SHOW -- AND HYPERTENSION AND
HYPERLIPIDEMIA IN THE FOLLOW-UP
POSTPARTUM PERIOD.
HOWEVER, WHEN WE ACCOUNT FOR THE
RISK FACTORS COMING IN TO
PREGNANCY, AND WE EXAMINE THE
PROPORTION MEDIATED, ONLY A
SMALL PROPORTION, LESS THAN 20%
OF THAT, IS MEDIATED BY THE
HYPERTENSIVE DISORDER OF
PREGNANCY FOR HYPERTENSION AND
THERE'S NO MEDIATION WITH
HYPERLIPIDEMIA.
THIS HIGHLIGHTS THE IMPORTANCE
OF ADVERSE PREGNANCY OUTCOMES AS
A MARKER AND NOT A MEDIATOR OF
THE ASSOCIATION WITH
CARDIOVASCULAR DISEASE RISK.
NOW THESE WERE EARLY OUTCOMES IN
THE SHORT TERM AND FUTURE
FOLLOW-UP STUDIES ARE STILL
NEEDED INCLUDING IN THIS COHORT
AND OTHERS.
SO LET'S MOVE ON TO THE NEXT
QUESTION, WHAT IS THE
EPIDEMIOLOGY OF ADVERSE
PREGNANCY OUTCOMES AND POTENTIAL
DRIVERS, WHAT DOES THE BURDEN
LOOK LIKE IN THE U.S.
POPULATION?
SO IF WE ZERO IN ON THE
SHORT-TERM PERIOD HERE IN THE
MIDDLE OF THIS CONCEPTUAL FIGURE
WE'VE BEEN USING, AS MANY OF YOU
ARE AWARE, CARDIOVASCULAR
DISEASE IS A LEADING CAUSE OF
MATERNAL DEATHS AND THE MATERNAL
MORTALITY RATIO IN THE IN 2018
IMAIRED OTHER HIGH-INCOME
COUNTRIES WHICH HAS
UNFORTUNATELY ONLY INCREASED
SINCE THEN IS MUCH HIGHER THAN
OTHER HIGH-INCOME COUNTRIES.
FURTHER, GREATER THAN 80% OF
THESE DEATHS ARE PREVENTIBLE,
WHICH WITH CARDIOVASCULAR
DISEASE BEING A LEADING CAUSE.
ONE OF THE THINGS THAT IS REALLY
STRIKING IS THAT A LOT OF THESE
PREGNANCY-RELATED DEATHS OCCUR
IN THE POSTPARTUM PERIOD, SO
MORE THAN TWO THIRDS OF DEATHS
ARE OCCURRING IN THE PERIOD
AFTER PREGNANCY, PARTICULARLY IN
THAT 43 TO 365 DAY POSTPARTUM
PERIOD WHEN MANY PEOPLE MAY NOT
EVEN CONSIDER THEMSELVES
POSTPARTUM ANYMORE, BUT
PARTICULARLY THOSE
CARDIOVASCULAR CONTRIBUTIONS
RELATED TO HYPERTENSION, STROKE,
CARDIOMYOPATHY, MAY STILL BE A
PROMINENT CAUSE OF THESE DEATHS.
IF WE LOOK AT THIS IN A
DIFFERENT WAY, THE ABSOLUTE
BURDEN, WHAT ARE THE COUNTS IN
2019 IN THE PRECOVID ERA TO GET
A SENSE OF THIS?
WELL, THERE'S NEARLY 300,000
LIVE BIRTHS THAT ARE COMPLICATED
BY HYPERTENSIVE DISORDERS, ABOUT
50,000 WITH MATERNAL MORBIDITY,
10,000 WITH ECLAMPSIA, AND A
SUBSTANTIAL NUMBER, OVER 6,000
REQUIRE ADMISSION TO AN ICU
DURING THE PREGNANCY OR DELIVERY
HOSPITALIZATION, AND ABOUT 754
MATERNAL DEATHS.
IF WE LOOK OVER TIME WE SEE
CONSISTENT INCREASES, SHOWN HERE
FROM 2007 TO 2019, AND FOR
GESTATIONAL DIABETES SHOWN HERE
FROM 2011 TO 2019.
IF WE LOOK BASED ON
SELF-IDENTIFIED RACE AND
ETHNICITY, WE SEE THE HIGHEST
RATES FOR HYPERTENSIVE DISORDERS
AMONG NON-HISPANIC BLACK
INDIVIDUALS AND THE HIGHEST RATE
FOR GESTATIONAL DIABETES AMONG
NON-HISPANIC ASIAN INDIVIDUALS.
ONE OF THE KEY QUESTIONS THAT
OFTEN COMES UP WHEN WE LOOK AT
THESE INCREASING TRENDS IS, IS
PART OF THE REASON THAT WE'RE
SEEING THESE PATTERNS AND
INCREASES BECAUSE OF INCREASING
MATERNAL AGE IN OUR POPULATION?
SO IF WE TAKE A LOOK AT THE
MATERNAL AGE DISTRIBUTION OVER
TIME, PARTICULARLY BETWEEN 2007
AND 2019, YOU CAN SEE HERE IN
THIS COLOR-CODED DIAGRAM THAT
WHILE THE MEAN AGE HAS INCREASED
BY TWO YEARS, THE MAJORITY OF
THAT INCREASE HAS ACTUALLY COME
FROM A POSITIVE OR FAVORABLE
DECLINE IN TEEN BIRTHS.
SO THERE'S BEEN SOME SHIFT WITH
GREATER BIRTHS OCCURRING IN THE
30 TO 34 OR THAT KNEE ON GREEN N
GREEN SHADED REGION, BUT A LOT
OF THIS CHAIJ HAS COME FROM A
FAVORABLE AGE DISTRIBUTION
CHANGE.
WHILE AGE IS INDEED A RELATIVE
RISK FACTOR, WHEREBY OLDER AGE
IS ASSOCIATED WITH HIGHER RISK
OF HYPERTENSIVE DISORDERS OF
PREGNANCY, IF WE LOOK AT THIS
FROM AN ABSOLUTE FRAMEWORK, WE
CAN SEE FROM THIS PIE CHART THAT
NEARLY 50% OF CASES OF NEW ONSET
HYPERTENSIVE DISORDERS ACTUALLY
OCCURRED IN INDIVIDUALS AGED 20
TO 29, SO THE PURPLE AND THE
GREEN COLOR HERE.
AND THAT REPRESENTS THAT A
GREATER PROPORTION OF
PREGNANCIES ARE OCCURRING IN
THIS AGE RANGE, BUT IT
HIGHLIGHTS THE IMPORTANCE OF WHO
MAY NORMALLY BE QUALIFIED AS NOT
GREATER THAN -- OR ADVANCED
MATERNAL AGE REALLY EXPERIENCING
A LARGE PROPORTION OF THE
ABSOLUTE BURDEN.
ANOTHER WAY TO LOOK AT THIS IS
RELATED TO BIRTH COHORT EFFECTS.
SO IF WE THINK ABOUT THE FACT
THAT OVER TIME, INDIVIDUALS
WHILE THE ACTUAL AGE AT WHICH
THEY'RE GIVING BIRTH IS THE SAME
BUT THEY THEMSELVES WERE BORN IN
A LATER PERIOD, SO IF SOMEBODY
WAS BORN BETWEEN 1996 TO 2004
SHOWN HERE IN THE DARK BLUE,
VERSUS SOMEBODY WHO WAS BORN IN
AN EARLIER BIRTH COHORT, YOU CAN
SEE BY THESE OVERLAPPING STACKED
LINES THAT INDIVIDUALS BORN IN
MORE RECENT GENERATIONS, 1996 TO
2004 IN THE ORANGE, 1991 TO
1999, ARE MUCH MORE LIKELY TO
EXPERIENCE A HYPERTENSIVE
DISORDER OF PREGNANCY EVEN AT
THE SAME AGE AT DELIVERY.
AND THIS REALLY HIGHLIGHTS THAT
THERE'S AN ADDITIONAL BIRTH
COHORT EFFECT THAT MAY BE
RELATED TO SECULAR TRENDS OR
POPULATION SHIFTS THAT HELP US
BETTER UNDERSTAND THAT THIS IS
NOT ALL SPECIFICALLY RELATED TO
AGE OR PERIOD EFFECT, BUT BETTER
UNDERSTANDING WHAT MAY BE
CHANGING IN BIRTH COHORTS FOR
PREGNANT INDIVIDUALS THEMSELVES.
SO WHAT MIGHT THAT BE?
SO LET'S TALK A LITTLE BIT ABOUT
THE RATIONALE FOR CARDIOVASCULAR
HEALTH PROMOTION AS PERHAPS THAT
ANTECEDENT DRIVER TO WHAT'S
CHANGING IN THE POPULATION AND
OPPORTUNITIES TO INTERVENE.
SO IF WE GO BACK TO OUR
CONCEPTUAL DIAGRAM, WE'VE GONE
THROUGH THE ADVERSE PREGNANCY
OUT COME COMPLICATIONS.
WE'VE LOOKED AT POSTPARTUM
CARDIOVASCULAR DISEASE RISK SO
LET'S SHIFT UPSTREAM.
AND TALK ABOUT PREPREGNANCY
CARDIOVASCULAR HEALTH, WHICH ARE
RISK FACTORS FOR SHORT-TERM
MATERNAL MORBIDITY AND MORTALITY
AND LONG TERM MORBIDITY AND
MORTALITY.
SO WHAT DATA DO WE HAVE FOR
PREPREGNANCY CARDIOVASCULAR
HEALTH AND ADVERSE PREGNANCY
OUTCOMES?
THESE ARE DATA FROM THE NATIONAL
CENTER FOR HEALTH STATISTICS,
WHEREBY BIRTH CERTIFICATES WERE
REVIEWED TO LOOK AT MATERNAL
CHARACTERISTICS, SPECIFICALLY A
CVH SCORE WAS CHARACTERIZED
BASED ON OBESITY, DIABETES
STATUS, HYPERTENSION STATUS AND
SMOKING STATUS.
SO A SCORE OF ZERO MEANT POOR
CARDIOVASCULAR HEALTH WITH A
GRADED DOSE DEPENDENT RESPONSE
ASSOCIATED WITH GREATER RISK OF
ADVERSE PREGNANCY OUTCOMES WITH
A HIGHER BURDEN OF THESE RISK
FACTORS, AND THAT WAS SEEN FROM
MATERNAL ICU ADMISSION, PRETERM
BIRTH AND LOW BIRTH WEIGHT.
IN ADDITION TO THESE MORE CRUDE
RISK FACTORS, THIS ANALYSIS FROM
THE NEW MOM TO BE STUDY LOOKED
SPECIFICALLY AT BLOOD PRESSURE
LEVELS, EVEN IN THE ABSENCE OF
CHRONIC HYPERTENSION REQUIRING
MEDICATION, AND WHAT THE
ASSOCIATION WITH COMPLICATIONS
OF PREECLAMPSIA AND BIRTH
COMPLICATIONS DURING PREGNANCY
WAS.
YOU CAN SEE IN THE CATEGORIES
HERE ABOUT 10% OF INDIVIDUALS
QUALIFIED IN THE STAGE ONE
HYPERTENSION CATEGORY, ABOUT 10%
HAD ELEVATED BLOOD PRESSURE, AND
THE MAJORITY HAD NORMAL BLOOD
PRESSURE.
AND SO YOU CAN ALREADY SEE THE
SEPARATION BASED ON HAVING AN
ELEVATED OR STAGE ONE
HYPERTENSION BLOOD PRESSURE IN
EARLY PREGNANCY AT A MEAN
GESTATIONAL AGE OF 12 WEEKS WITH
A HIGHER RISK OF PRE-ECLAMPSIA
NOW WHEN GESTATIONAL
HYPERTENSION WAS ADDED THERE WAS
EVEN A HIGHER ONE IN THREE RISK
OF DEVELOPING EITHER GESTATIONAL
HYPERTENSION OR PREECLAMPSIA AND
THOSE IN THE STAGE ONE GROUP HAD
A 40% INCIDENCE OF DEVELOPING
EITHER GESTATIONAL HYPERTENSION
OR PRE-ECLAMPSIA THE OTHER
INTERESTING THING WAS AMONG
THOSE WHO HAD AN INCREASE IN
BLOOD PRESSURE FROM THIS FIRST
TRIMESTER TO SECOND TRIMESTER
VISIT WERE MUCH MORE LIKELY TO
DEVELOP PREECLAMPSIA AS WELL,
HIGHLIGHTING THE DYNAMIC NATURE
OF BLOOD PRESSURE CHANGE DURING
PREGNANCY AS AN IMPORTANT
PREDICTOR.
WHILE THESE DATA HELP US
IDENTIFY THAT PREPREGNANCY
CARDIOVASCULAR HELP AS WELL
AS -- ARE REALLY IMPORTANT FOR
PREGNANCY COMPLICATION AND LONG
TERM CARDIOVASCULAR RISK, IF WE
TAKE A LOOK AT THE OVERALL
POPULATION CHANGE, WE SEE
CARDIOVASCULAR HEALTH IS
DECLINING OVERALL IN ALL
INDIVIDUALS.
RATES OF OBESITY AND SEVERE
OBESITY ARE INCREASING, RATES OF
PREDIABETES AND DIABETES, AND
PARTICULARLY AMONG ADOLESCENTS
AND YOUNG ADULTS, WHO ARE IN
THEIR REPRODUCTIVE YEARS.
DATA FROM THE NATIONAL CENTER
FOR HEALTH STATISTICS HELPS US
ALSO LOOK AT SOME OF THESE
TRENDS WHEREBY IN EACH AGE
GROUP, SHOWN HERE FOR 15 TO 24,
25 TO 34 AND 35 TO 44, WE SEE A
DECLINE IN OPTIMAL
CARDIOVASCULAR HEALTH, WHEREBY
OPTIMAL IS DEFINED AS NORMAL
BMI, ABSENCE OF DIABETES OR
HYPERTENSION.
IN THE SECOND FIGURE, WE SEE
THAT THERE ARE ALSO SIGNIFICANT
DISPARITIES BY ADVERSE SOCIAL
FACTORS AS DESIGNATED BY
QUALIFYING OR RECEIVING WIC
SUPPORT DURING PREGNANCY.
YOU SEE THAT SIGNIFICANT
DIFFERENCE IN OPTIMAL CVH IN
THOSE RECEIVING WIC SUPPORT AS
WELL AS CONSISTENT DECLINES FOR
BOTH.
SO I POSIT AND HOPEFULLY WHAT
WE'VE LOOKED AT SO FAR
HIGHLIGHTS THAT MATERNAL
MORBIDITY IS REALLY THE TIP OF
THE ICEBERG WHEN WE'RE THINKING
ABOUT BOTH PREGNANCY-SPECIFIC
COMPLICATIONS AND LONG TERM
CARDIOVASCULAR HEALTH.
AND REALLY WHAT WE WANT TO DO IS
MOVE BELOW THE SURFACE TO THINK
ABOUT THE GREATER POPULATION
LEVEL IMPACT THAT WE CAN HAVE
WITH A FOCUS ON CARDIOVASCULAR
HEALTH THROUGHOUT THE PERIPARTUM
PERIOD.
AHA, ACC AND ACOG HAVE ALL
HIGHLIGHTED THE REPRODUCTIVE
YEARS AS AN IMPORTANT PERIOD TO
FOCUS ON CARDIOVASCULAR HEALTH
PROMOTION, AND AN AHA/ACOG
COMBINED PRESIDENTIAL ADVISORY
THAT PROMOTED RISK
IDENTIFICATION AND REDUCTION OF
CARDIOVASCULAR DISEASE DURING
THE REPRODUCTIVE YEARS.
ONE OF THE KEY PHRASES THAT HAS
BECOME MORE AND MORE COMMON IS
THIS IDEA OF A FOURTH TRIMESTER,
THE 12 WEEKS THAT FOLLOW
DELIVERY, AS A KEY TIME FOR
THOSE WHO HAVE DELIVERY
COMPLICATED BY ADVERSE PREGNANCY
OUTCOMES TO BE CONNECTED TO AND
TRANSITION TO PRIMARY CARE.
THIS NICE SCHEMATIC FROM A
RECENT REVIEW IN JAMA CARDIOLOGY
HIGHLIGHTED THIS GROWING CONCEPT
OF TRANSITIONAL CLINICS THAT CAN
PERFORM EDUCATION, COUNSELING,
SCREENING AND RISK ASSESSMENT,
MEDICATION MANAGEMENT AND THAT
IMPORTANT TRANSITION TO PRIMARY
CARE FOR INDIVIDUALS WHO ARE
IDENTIFIED AS HAVING HIGHER RISK
DUE TO THEIR COMPLICATION OF
ADVERSE PREGNANCY OUT COME.
OUTCOME.
ONE OF THE CHALLENGES WITH THIS
CONSTRUCTION HAS BEEN THE
INABILITY FOR INDIVIDUALS TO
COME IN IN PERSON, ESPECIALLY
WITH THE COVID PANDEMIC, THE
INCREASING USE OF TELEHEALTH
MADE DIAGRAMS OR CONSTRUCTS LIKE
THIS MORE AVAILABLE.
THIS WAS A REPORT THAT WAS
PUBLISHED FROM A ACADEMIC CENTER
THAT INCORPORATED A
MULTIDISCIPLINARY TELEHEALTH
CLINIC TO ALLOW INDIVIDUALS TO
BE ABLE TO GO HOME SOONER WITH
HOME BLOOD PRESSURE MONITORING
PROGRAMS, AS WELL AS STAY IN AN
EXTENDED HOME BLOOD PRESSURE
MONITORING PROGRAM POSTPARTUM TO
CONTINUE TO MONITOR CLOSELY FOR
BLOOD PRESSURE COMPARED WITH THE
STAN
STANDARD OF CARE WHICH AFTER
THAT FIRST 14 DAY BLOOD PRESSURE
CHECK MAY HAVE LEFT WITH
SOMETHING -- WITH THE CLINIC
VISIT SOMEWHERE IN THE 2 TO
6 MONTH PERIOD AND REALLY A LOT
OF PEOPLE GETTING LOST AND NOT
HAVING FOLLOW-UP.
IT'S REALLY IMPORTANT TO THINK
ABOUT AMONG INDIVIDUALS WHO
EXPERIENCE A HYPERTENSIVE
DISORDER OF PREGNANCY, MANY NO
LONGER NEED MEDICATIONS, AND MAY
NOT BE CLOSELY FOLLOWED FOR
OPTIMAL LIFESTYLE INTERVENTIONS.
SO THIS REALLY NICE WORK THAT
WAS FUNDED BY NHLBI ASKED THE
QUESTION OF TEXT-BASED
GAMIFICATION, SO COULD WE
PROMOTE PHYSICAL ACTIVITY IN A
GAMIFIED APPROACH TO HELP
IMPROVE STEP COUNTS?
SO THE STUDY LOOKED AT 127
PARTICIPANTS WITH A MEAN AGE OF
32 WHO HAD EXPERIENCED A
HYPERTENSIVE DISORDER OF
PREGNANCY AND RANDOMIZED THEM TO
A TEXT-BASED GAMIFICATION
APPROACH WHERE BOTH CONTROL AND
INTERVENTION RECEIVED A FITBIT
TO TRACK THEIR STEP COUNTS, AND
YOU SEE HERE THAT THE
INTERVENTION SHOWN IN THE DARK
RED HAD A MUCH HIGHER STEP COUNT
THAN THE CONTROL.
NOW, I ALSO DO WANT TO POINT OUT
THAT THE DELTA HERE WAS ABOUT
600 STEPS, WHICH IS ABOUT A
THIRD OF A MILE OR ON AN AVERAGE
WALKING PACE ABOUT FIVE MINUTES
OF WALKING EXTRA PER DAY.
NOW, WHILE THAT MAY NOT SEEM
LIKE A LOT, THE COMBINATION OF
DOING THAT ON A FREQUENT AND
CONTINUOUS BASIS MAY HAVE
LONG-STANDING EFFECT, BUT I
THINK ONE OF THE CHALLENGE THAT
WE CONTINUE TO HAVE IS HOW DO WE
SUSTAIN INCREASES AND MAINTAIN
PHYSICAL ACTIVITY IN BIRTHING
ADULTS AS WELL AS ALL ADULTS.
ONE OF THE OTHER STRATEGIES THAT
HAS BEEN PROMOTED HAS BEEN THE
SUPPORT OF LACTATION TO PROMOTE
METABOLIC HEALTH POSTPARTUM.
THE FIRST GRAPH HERE SHOWS SOME
REALLY NICE DATA FROM THE CARDIA
COHORT, LOOKING AT DURATION OF
LACTATION FROM NONE TO GREATER
THAN ZERO TO SIX MONTHS, 6 TO
12, GREATER THAN OR EQUAL TO 12,
AND COMBINED WITH ANY
LACTATION -- OR COMBINED WITH
THE OVERALL POPULATION TO LOOK
AT THE INCIDENCE OF DIABETES IN
FOLLOW-UP, AND YOU CAN SEE THOSE
INDIVIDUALS THAT HAD GREATER
DURATION OF LACTATION HAVE LOWER
INCIDENCE OF DIABETES, AND WHEN
YOU STRATIFY BY GESTATIONAL
DIABETES OR NON-GESTATIONAL
DIABETES, YOU SEE A SIMILAR
PATTERN.
SO THERE IS AN EFFECT
MODIFICATION BY GESTATIONAL
DIABETES STATUS.
SO THAT IS OBSERVATIONAL DATA
THAT SUPPORTS AN ASSOCIATION.
UNFORTUNATELY, GIVEN THE
STRUCTURAL AND PERSONAL BARRIERS
THAT MAY EXIST TO LACTATION, WE
DO SEE VERY LOW RATES IN THE
UNITED STATES WITH AT 6 MONTHS,
ANY BREASTFEEDING AT ABOUT 56%
AND EXCLUSIVE BREASTFEEDING AT
25%.
WE KNOW THERE ARE MANY BARRIERS
THAT EXIST INCLUDING AT A POLICY
LEVEL WITH NEED FOR PARENTAL
LEAVE AT A COMMUNITY LEVEL,
INSTITUTIONAL, INTERPERSONAL AND
INDIVIDUAL LEVEL THAT CAN REALLY
CREATE CHALLENGES FOR SUPPORTING
LACTATION.
UNDERSTANDING THESE CHALLENGES
AND ADDRESSING THEM IN AN
EQUITABLE FRAMEWORK SHOWN HERE
AS A SOCIOECOLOGICAL MODEL THAT
CAN REALLY THINK ABOUT THIS AT A
POLICY LEVEL AND ORGANIZATIONAL
LEVEL, COMMUNITY LEVEL, AS WELL
AS INDIVIDUAL LEVEL S REALLY
IMPORTANT.
ONE OF THE THINGS THAT CAN OFTEN
OCCUR WHEN WE TALK ABOUT
LACTATION SUPPORT IS ALL OF THIS
FOCUS THAT OCCURS ON THE
BIRTHING ADULT, WITHOUT
CONSIDERATION FOR THE EXTERNAL
DRIVERS THAT MAY BE OUT OF THEIR
CONTROL THAT CAN OFTEN
EXACERBATE AN ALREADY DIFFICULT
SITUATION.
SO WE'RE LOOKING AT A LOT OF
THIS DATA THAT HELP US IDENTIFY
THE POSTPARTUM PERIOD AS AN
IDEAL TIME TO MEASURE AND MODIFY
CARDIOVASCULAR HEALTH.
SO HOW CAN WE DO IT?
IN JAMA LAST YEAR, WE PROPOSED
LEVERAGING THE LIFE'S ESSENTIAL
8 FRAMEWORK, REALLY AS A
CONTINUOUS TIME THINKING ABOUT
THE PREPREGNANCY PERIOD, THE
PREGNANCY PERIOD, AND THE
POSTPARTUM PERIOD TO THINK ABOUT
MEASUREMENT AND MODIFICATION AS
NEEDED OF THESE EIGHT COMPONENTS
OF LIFE'S ESSENTIAL EIGHT,
SPECIFICALLY, DIETARY
ASSESSMENT, PHYSICAL ACTIVITY,
NICOTINE EXPOSURE AND AVOIDANCE,
SLEEP HEALTH, WHICH WAS THE
NEWEST VARIABLE THAT WAS
INCLUDED IN THE AHA
CARDIOVASCULAR HEALTH CONSTRUCT,
BODY MASS INDEX, BLOOD PRESSURE
MONITORING, BLOOD GLUCOSE AND
BLOOD LIPID SCREENING.
ONE OF THE THINGS THAT WE
HIGHLIGHTED WAS THE IMPORTANCE
OF DIET AND PHYSICAL ACTIVITY
SCREENING WITHIN THE CLINICAL
SYSTEM THAT IS OFTEN NOT COVERED
BOTH AT THE POSTPARTUM VISIT OR
IN TRANSITIONS TO PRIMARY CARE.
THE OTHER QUESTION THAT REMAINS
IS HOW FREQUENTLY SHOULD BLOOD
PRESSURE, BLOOD GLUCOSE AND
BLOOD LIPIDS BE MEASURED AFTER
AN INDIVIDUAL IS POSTPARTUM, HOW
SOON AFTER POSTPARTUM AND HOW
FREQUENTLY, AND SHOULD THAT
DIFFER FOR INDIVIDUALS WITH
ADVERSE POST PREGNANCY OUT COME,
GOING ON TO DEVELOP CHRONIC
HYPERTENSION AND DIABETES.
WHEN WE TALK ABOUT POSTPARTUM
INTERVENTIONS, IT'S IMPORTANT TO
REMEMBER THAT THESE COULD ALSO
SERVE AS INTERPREGNANCY
INTERVENTIONS, WHILE POSTPARTUM
MAY HELP TO MODIFY
CARDIOVASCULAR HEALTH ACROSS THE
LIFE COURSE FOR THE BIRTHING
INDIVIDUAL, OFTENTIMES PEOPLE
MAY BECOME PREGNANT AGAIN AND
THIS REPRESENTS AN END TERM
PREGNANCY INTERVENTION OR
PRETERM PREGNANCY INTERVENTION
FOR THE NEXT PREGNANCY.
NEXT SLIDE.
IT'S REALLY IMPORTANT WHEN WE
THINK ABOUT PREGNANCY
CARDIOVASCULAR HEALTH AND
POSTPARTUM CARDIOVASCULAR HEALTH
TO REMEMBER THAT THIS IS
SOMETHING THAT TRACKS VERY
CONSISTENTLY.
AND OFTENTIMES WHERE POSTPARTUM
CARDIOVASCULAR HEALTH IS, IS
REALLY DEFINED BY WHERE
PREGNANCY CARDIOVASCULAR HEALTH
IS, WHICH IS DEFINED BY
PREPREGNANCY CARDIOVASCULAR
HEALTH.
AND THIS WAS THE FOCUS OF A
RECENT AHA SCIENTIFIC STATEMENT
THAT I WAS FORTUNATE TO WORK ON
WITH DR. WEI FROM THE NHLBI AND
MANY OR COLLEAGUES THAT
HIGHLIGHTED THE IMPORTANCE OF
THE PREPREGNANCY PERIOD AS
PERHAPS THE ZERO TRIMESTER, A
PERIOD OF TIME WHERE WE MAY HAVE
THE GREATEST YIELD BY BEING ABLE
TO FOCUS ON OPTIMIZING
CARDIOVASCULAR HEALTH BEFORE AN
INDIVIDUAL BECOMES PREGNANT.
AND IF WE THINK ABOUT THIS
WITHIN THE LIFECYCLE OR FULL
LIFE COURSE, THE PREPREGNANCY
PERIOD REALLY INFORMS PREGNANCY
AND INTERPREGNANCY
CARDIOVASCULAR HEALTH AND FUTURE
RISK FOR CARDIOVASCULAR DISEASE
FOR THE BIRTHING INDIVIDUAL, AS
WELL AS THE IMPORTANCE OF
OFFSPRING CARDIOVASCULAR HEALTH
WHICH HAS ALSO BEEN DEMONSTRATED
IN OBSERVATIONAL COHORT STUDIES.
WE WANTED TO FOCUS ON SOME OF
THE FOUNDATIONAL DETERMINANTS OF
CARDIOVASCULAR HEALTH WITHIN
THIS STATEMENT, PARTICULARLY
WITH THE IMPORTANCE OF STRESS
AND RESILIENCE, SOCIAL DETERMINE
NANCE AND STRUCTURAL POLICIES
THAT ALL NEED TO BE APPROACHED
IF WE ARE GOING TO OPTIMIZE
CARDIOVASCULAR HEALTH BROADLY IN
PREGNANT AND POSTPARTUM
INDIVIDUALS AND OFFSPRING.
ONE OF THE THINGS THAT REPEATED
MEASUREMENTS IN COHORTS IS
HIGHLIGHTED WITH CARDIOVASCULAR
HEALTH IS THE YOUNG ADULT PERIOD
OR THE REPRODUCTIVE YEARS, OFTEN
SHOW CRITICAL PERIODS OF DECLINE
IN CARDIOVASCULAR HEALTH.
SHOWN IN THE FIRST PANEL HERE
ARE CLINICAL CARDIOVASCULAR
HEALTH SCORES FROM FIVE
POPULATION-BASED COHORTS THAT
IDENTIFIED FIVE DIFFERENT
TRAJECTORIES SHOWING OVERALL
DECLINE WITH SOME MORE RAPID
DECLINE THAN OTHERS, BUT REALLY
HIGHLIGHTING THIS PERIOD OF TIME
IN YOUNG ADULTHOOD.
IN AN OLDER STUDY FROM THE NGHS,
SHOWN HERE ARE CARDIOVASCULAR
HEALTH PROFILES FROM OVER 2,000
INDIVIDUALS AGED 9 TO 19 THAT
WERE FOLLOWED ANNUALLY FOR THAT
PERIOD OF TIME, AND AGAIN, WE
SEE A SIMILAR PATTERN OF VARYING
CARDIOVASCULAR HEALTH DECLINE,
WHERE AN INDIVIDUAL STARTED MAY
INFORM WHERE THEY END UP, BUT
STILL DIFFERING PATTERNS OVER
THIS TIME PERIOD.
ONE OF THE MOST IMPORTANT
PRETICK TORES AND WHO
PREDICTORS AND WHO HAD THE MOST
DECLINE IN TEENAGE GIRLS WAS THE
INCIDENCE OF PREGNANCY.
SO THIS WAS REALLY HIGHLIGHTING
THAT PREGNANCY CAN BE AN
INFLECTION POINT, UNFORTUNATELY
FOR WORSENING CARDIOVASCULAR
HEALTH BUT ALSO IDENTIFIES AN
OPPORTUNITY FOR TARGETING
CARDIOVASCULAR HEALTH DURING
THIS CRITICAL PERIOD.
BUT GAPS EXIST THAT PREVENT
IDEAL CARDIOVASCULAR HEALTH FOR
BIRTHING INDIVIDUALS AND I
WANTED TO HIGHLIGHT THESE FOUR
AREAS.
FIRST, AWARENESS OF
CARDIOVASCULAR DISEASE RISK BY
INDIVIDUALS THEMSELVES, AS WELL
AS CLINICIANS.
AND FOLLOWING THAT, AWARENESS OF
ADVERSE PREGNANCY OUTCOMES AS
CARDIOVASCULAR DISEASE RISK
ENHANCERS.
IN ORDER TO BETTER ESTIMATE
RISK, ENSURING THAT
CARDIOVASCULAR RISK PREDICTION
TOOLS ARE AVAILABLE FOR ADULTS
AND ENSURING WE DO THIS IN THE
CONTEXT OF SOCIAL AND STRUCTURAL
FACTORS SUCH AS SOCIAL
DETERMINANTS OF HEALTH.
MANY OF YOU ARE PROBABLY
FAMILIAR WITH THESE DATA THAT
ARE HIGHLIGHTED FROM THE
AMERICAN HEART ASSOCIATION THAT
DEMONSTRATED THAT THERE IS AN
UNDERAPPRECIATION OR
UNDERAWARENESS BY INDIVIDUALS
FOR THE LEADING CAUSE OF DEATH
AMONG WOMEN -- HEART DISEASE.
REPORTED THAT HEART DISEASE WAS
THEIR LEADING CAUSE OF DEATH,
THIS DROPPED TO BELOW 50%.
IN A SURVEY LED AT OUR CENTER,
WE SURVEYED 700 POSTPARTUM
PEOPLE AND ONLY ABOUT 50% OF
INDIVIDUALS WHO HAD EXPERIENCED
AN ADVERSE PREGNANCY OUTCOME
RECOGNIZED THAT THEIR
CARDIOVASCULAR DISEASE RISK WAS
HIGHER THAN AVERAGE.
AND WE'VE SEEN SIMILAR STUDIES
FROM OTHER CENTERS AS WELL AS
FROM A CLINICAL PER EXECUTIVE OF
CLINICIANS NOT BEING AWARE OF
THIS RISK AS WELL.
WE ALSO KNOW THAT THERE ARE GAPS
IN CARDIOVASCULAR DISEASE
GUIDELINES AFTER AN ADVERSE
PREGNANCY OUTCOME.
WHILE THE 2019 PRIMARY
PREVENTION GUIDELINES RECOMMEND
RISK ASSESSMENT WITH THE POOLED
COHORT EQUATIONS AND HIGHLIGHT
ADVERSE PREGNANCY OUTCOMES AS
RISK ENHANCING FACTORS, THERE
ARE NO SPECIFIC RECOMMENDATIONS
FOR THOSE WHO EXPERIENCE AN
ADVERSE PREGNANCY OUT COME.
IN FACT, CURRENT RECOMMENDATIONS
FOR YOUNG ADULTS ALSO FOCUS ON
RISK ASSESSMENT WITH 30-YEAR
RISK BUT THE POOLED COHORT
EQUATIONS BEGIN AT AGE 40.
ONE WAY WE WERE ABLE TO RECENTLY
ADDRESS THIS WAS WITH A
DEVELOPMENT AND VALIDATION OF
THE 2023 PREDICTING RISK IN
CARDIOVASCULAR DISEASE EQUATIONS
OR THE PREVENT EQUATIONS WHICH
NOW ENABLE RISK CALCULATION AT
AGE 30 AND INCLUDE 10-YEAR AND
30-YEAR RISK ESTIMATION.
AS WE SAID PORPLY, ASSESSING AND
ADDRESSING SOCIAL DETERMINANTS
OF HEALTH WHICH ARE THE
FUNDAMENTAL CAUSES OF HEALTH
INEQUITY ARE NEEDED.
AND A VERY, I THINK, POINTED
QUOTE FROM KAREN JOINT MADDOX
I'VE HEARD BEFORE WHICH I THINK
IS HIGHLY RELEVANT HERE IS THAT
STRUCTURAL PROBLEMS REQUIRE
STRUCTURAL SOLUTIONS, SO BEING
ABLE TO FOCUS ON THIS AS WE MOVE
FORWARD IS CRITICAL.
SO WHAT ABOUT QUESTIONS THAT ARE
UNANSWERED?
AND HOW DO WE FILL THESE GAPS
THAT EXIST?
AND IF WE FOCUS ON MEASURING AND
MODIFYING CARDIOVASCULAR HEALTH,
I'M GOING TO CONCLUDE WITH FOUR
KEY QUESTIONS.
HOW SHOULD WE MONITOR AND TREAT
BLOOD PRESSURE AS A KEY TARGET
IN THE POSTPARTUM PERIOD?
WHAT ARE THE PATHWAYS,
PREDICTORS AND MEDIATORS TO
CLINICAL CARDIOVASCULAR DISEASE?
HOW DO WE INTEGRATE THE NEW
CONSTRUCT OF CARDIOVASCULAR
KIDNEY METABOLIC HEALTH THAT THE
AMERICAN HEART ASSOCIATION
RECENTLY RELEASED THAT BUILDS ON
THE CONCEPT OF LIFE'S ESSENTIAL
EIGHT AND CARDIOVASCULAR HEALTH,
AND LOW DO WE DESIGN MULTILEVEL
INTERVENTIONS FOR CARDIOVASCULAR
HEALTH EQUITY.
IN TERMS OF WHEN AND HOW TO
TREAT BLOOD PRESSURE POSTPARTUM,
THERE ARE LIMITED DATA IN BLOOD
PRESSURE DURING PREGNANCY AND
POSTPARTUM THAT HAVE FOLLOWED
INDIVIDUALS THROUGHOUT THESE TWO
TIME PERIODS.
AND THIS IS SOME DATA THAT SHOW
THAT INDIVIDUALS WHO HAVE A
HYPERTENSIVE DISORDER OF
PREGNANCY MAY FOLLOW TWO
DIFFERENT TRAJECTORIES.
SOME REMAIN ELEVATED AND SOME
RETURN BACK TO NORMAL.
BUT HOW DO WE KNOW WHO ENDS IN
WHICH GROUP AND HOW TO TREAT
THEM BEST?
IN AN R34 FUNDED BY NHLBI, THIS
QUESTION IS BEING STUDIED IN A
PILOT STUDY TO LOOK AT MORE
INTENSIVE AND LESS INTENSIVE
BLOOD PRESSURE CONTROL IN EARLY
POSTPARTUM.
AND STARTING TO ADDRESS THIS
QUESTION OF WHAT ARE THE OPTIMAL
BLOOD PRESSURE GOALS AFTER
HYPERTENSIVE DISORDERS IN THE
POSTPARTUM PERIOD, AND HOW EARLY
SHOULD INTERVENTIONS BEGIN?
I THINK AS WE THINK ABOUT THESE
QUESTIONS, OTHER RELATED
QUESTIONS THAT WE NEED TO BETTER
UNDERSTAND INCLUDE HOW DO WE
SUPPORT AND SUPPLEMENT
ANTIHYPERTENSIVE THERAPY WITH
LIFESTYLE, BEHAVIORAL
INTERVENTIONS IN THIS PERIOD?
SHOULD ASPIRIN OR STATINS BE
USED IN THIS PERIOD?
OR IN THE SHORT TERM AFTER A
HYPERTENSIVE DISORDER OF
PREGNANCY?
AND SHOULD WE TARGET
INTERVENTIONS EVEN AMONG THOSE
WHO DON'T EXPERIENCE A
HYPERTENSIVE DISORDER BUT HAVE
ELEVATED BLOOD PRESSURE ALONE?
SECOND IS HOW DO WE DEFINE THE
PATHWAYS AND MECHANISMS IN THE
PERIPARTUM PERIOD?
WE KNOW THAT CLINICAL
CARDIOVASCULAR DISEASE OFTEN
OCCURS IN THE SIXTH DECADE OF
LIFE BUT THE ORIGINS OF DISEASE
BEGIN MUCH EARLIER.
AUTOPSY STUDIES HIGHLIGHT BY THE
SECOND DECADE OF LIKE, THERE ARE
PLAQUES ALREADY DEVELOPING AND
PROGRESSING EVEN AS EARLY AS AGE
20s AND 30s WHEN PEOPLE MAY
BE BECOMING PREGNANT.
SO SUBCLINICAL MEASURES OF
CARDIOVASCULAR DISEASE WITH
ULTRASOUND SPECIFICALLY CAN BE
VERY USEFUL, AND IN THIS
R01 FUNDED BY NHLBI, WHICH IS
ANCILLARY TO THE NEW MOM TO BE
HEART HEALTH STUDY, WE'RE
CURRENTLY DOING CAROTID
ULTRASOUND TO LOOK AT VASCULAR
INJURY AS WELL AS THICKNESS TO
BETTER UNDERSTAND THE PATHWAYS
FROM EARLY PREG SEAL WHEN THESE
INDIVIDUALS WERE FIRST RECRUITED
TO RIGOROUS ADJUDICATION OF
PREGNANCY OUTCOMES AND FOLLOW-UP
MEASURES ABOUT 10 YEARS DO DOWNE
ROAD.
THIRD, THIS QUESTION OF HOW DO
WE BROADEN AND THINK ABOUT MORE
INCLUSIVELY KIDNEY HEALTH,
METABOLIC HEALTH AND
CARDIOVASCULAR DISEASE RISK FOR
THE PREGNANT AND POSTPARTUM
INDIVIDUAL?
LAST YEAR THE AHA RELEASED THIS
PRESIDENTIAL ADVISORY WHICH I
WAS FORTUNATE TO WORK WITH THIS
AMAZING TEAM ON DEFINING
CARDIOVASCULAR KIDNEY METABOLIC
SYNDROME AS A HEALTH DISORDER
DUE TO CONNECTIONS AMONG HEART
DISEASE, KIDNEY DISEASE,
DIABETES AND OBESITY LEADING TO
POOR HEALTH OUTCOMES, NOTINGLY
WE INCLUDED GESTATIONAL DIABETES
AND HYPERTENSIVE DISORDERS OF
PREGNANCY WITHIN THE FRAMEWORK,
BUT I THINK ONE THING THAT WE
REALLY NEED TO BUILD ON AS WE
THINK ABOUT THE PERIPARTUM
PERIOD IS HOW DO WE INTEGRATE
THE STAGING INTO THIS POPULATION
FOR DELIVERY OF CARE.
LAST, HOW DO WE THINK ABOUT THE
WHOLE PICTURE WITHIN A
SOCIOECOLOGICAL FRAMEWORK THAT
LOOKS AT POLICIES, COMMUNITY
ENGAGED INTERVENTIONS, HEALTH
SYSTEM BASED INTERVENTIONS AS
WELL AS THE INDIVIDUAL PATIENT
CLINICIAN.
SHOWN HERE ARE SOME EXAMPLES OF
POLICIES THAT COULD BE
CONSIDERED AND ARE CURRENTLY
BEING CONSIDERED INCLUDING
POSTPARTUM MEDICAID EXTENSION
AND SMOKING BANS, THINKING ABOUT
COMMUNITY ENGAGED INTERVENTIONS,
TARGETING CHURCH-BASED
INTERVENTIONS AND BARBERSHOP
INTERVENTIONS FOR LOWERING BLOOD
PRESSURE, HEALTH SYSTEM
INTERVENTIONS LIKE REMOTE PLOOPD
PRESSURE MONITORING AND AT THE
INDIVIDUAL CLINICIAN-PATIENT
LEVEL.
ONE OF THE PROJECTS THAT I AM
REALLY EXCITED TO BE WORKING ON
WITH DR. CHARLOTTE PRATT FROM
NHLBI AS WELL AS DR. PRICE AND
DR. DONZE AND MANY OTHERS IS THE
ENRICH STUDY, THE EARLY
INTERVENTION TO PROMOTE
CARDIOVASCULAR HEALTH OF MOTHERS
AND CHILDREN.
SHOWN HERE ARE THE SITES THAT
ARE INVOLVED IN THE ENRICH
PROJECT, AND IF WE GO BACK A
SLIDE, JUST HIGHLIGHTING SOME OF
THE KEY INNOVATIONS OF ENRICH
INCLUDE THE APPROACH USING
EVIDENCE-BASED -- TO LEVERAGE
EXISTING SETTINGS WHERE FAMILIES
WHO HAVE ADVERSE SOCIAL FACTORS
ARE ALREADY RECEIVING CARE TO
ALLOW A SCALABLE APPROACH WITH A
FOCUS ON HEALTH EQUITY.
THE ENRICH STUDIES ALSO FOCUSING
ON TWO GENERATIONS, BOTH PARENT
AND CHILD, THAT UNIQUELY WILL
EXAMINE AN INTERVENTION AND
MEASURE CVH IN A REMOTE
DECENTRALIZED TRIAL DESIGN.
SO I WANT TO SUMMARIZE WHAT
WE'VE TALKED ABOUT WITH THREE
KEY TAKEAWAYS.
THE REPRODUCTIVE LIFE COURSE
FRAMEWORK OR THAT CONCEPTUAL
FIGURE WE USE HIGHLIGHTS THE
PERIPARTUM PERIOD AS A WINDOW OF
OPPORTUNITY WHEN RISK FOR
CARDIOVASCULAR DISEASE IS
UNMASKED.
SECOND, WE LOOKED AT SECULAR
TRENDS SHOWING POPULATION LEVEL
DECLINES IN OPTIMAL
CARDIOVASCULAR HEALTH AS REALLY
THE MAJOR DRIVER OF ADVERSE
TRENDS AND ADVERSE PREGNANCY
OUTCOMES EVEN IN YOUNGER
GENERATIONS AND PARTICULARLY IN
YOUNGER GENERATIONS WITH
PERSISTENT RACIAL AND ETHNIC
DISPARITIES.
AND THIRD, A SHIFT TOWARDS
GENERATING AND IMPLENTYING
EVIDENCE BASE TO MEASURE, MODIFY
AND MONITOR CVH AND PERHAPS NOW
MORE BROADLY CARDIOVASCULAR
KIDNEY METABOLIC HEALTH IS
NEEDED TO ACHIEVE HEALTH EQUITY.
SO I'M GOING TO END WITH THE
ANALOGY THAT WE STARTED WITH IN
TERMS OF PREGNANCY AS A WINDOW
TO FUTURE CARDIOVASCULAR HEALTH
AND PROPOSE THAT WE THINK ABOUT
THE FULL PERIPARTUM SPECTRUM AS
OUR IDEAL WINDOWS OF OPPORTUNITY
TO IMPROVE CARDIOVASCULAR HEALTH
AND CARDIOVASCULAR KIDNEY
METABOLIC HEALTH.
WONDERFUL.
THANK YOU SO MUCH FOR YOUR TIME
AND ATTENTION, AND LOOK FORWARD
TO THE DISCUSSION AND Q & A.
>> WONDERFUL.
THANK YOU, DR. KHAN, FOR YOUR
EXCELLENT PRESENTATION.
THIS IS A VERY TIMELY TOPIC
ESPECIALLY IN WITH THE INCREASE
OF ADVERSE PREGNANCIES IN RECENT
YEARS SO I'M VERY EXCITE TODAY
HAVE THIS DISCUSSION.
I WOULD LIKE TO REMIND THE
AUDIENCE TO PLEASE EMAIL YOUR
QUESTIONS TO ONPA@MAIL.NIH.GOV,
OR YOU CAN SUBMIT THEM THROUGH
THE LIVE FEEDBACK IN THE
VIDEOCAST.
AS THE QUESTIONS ARE COMING IN,
DR. KHAN, I WOULD LIKE TO
PROPOSE -- OR POSE ONE QUESTION
TO YOU.
SO FIRST I REALLY LOVE THAT YOU
DISCUSSED THE -- OR AT LEAST
MENTIONED THE MENOPAUSAL AND
POST-MENOPAUSAL PERIODS AS A
PART OF THE POSTPARTUM PHASE OF
A WOMAN'S LIFE.
I THINK WE OFTEN DON'T THINK
ABOUT THAT.
TYPICALLY AS YOU SAID, WE OFTEN
CONSIDER JUST THAT UP TO THE ONE
YEAR, RIGHT, POST BIRTH.
SO DO YOU KNOW IF THERE ARE ANY
STUDIES THAT HAVE BEEN PUBLISHED
LINKING PERINATAL HEALTH TO
CARDIOVASCULAR HEALTH, EITHER
DURING THE MENOPAUSAL TRANSITION
OR POST-MENOPAUSAL PERIODS?
>> IT'S A REALLY GREAT QUESTION,
AND I THINK IT HELPS TO
CONCEPTUALIZE THAT FULL LIFE
COURSE APPROACH, WHERE WE'RE
THINKING ABOUT PREGNANCY AND
MENOPAUSE AS BOTH BEING REALLY
KEY LIFE EVENTS IN A
PREGNANCY-CAPABLE INDIVIDUAL
WHEN SIGNIFICANT METABOLIC
CHANGES ARE HAPPENING.
I THINK BOTH OF THOSE
TRANSITIONS ARE OFTEN KIND OF
ASSOCIATED WITH ADVERSE CHANGES
IN CARDIOMETABOLIC FACTORS, BUT
IT'S STILL UNCLEAR WHETHER OR
NOT THOSE ARE MARKERS OR
MEDIATORS OF THOSE CHANGES THAT
ARE OCCURRING THEN.
IN TERMS OF THE LINK BETWEEN
ADVERSE PREGNANCY OUTCOMES AND
MENOPAUSAL HEALTH OR
CARDIOMETABOLIC HEALTH OR
CHANGES DURING MENOPAUSE, I
THINK THE BEST STUDY THAT
PROBABLY HAS TRACKED THEM MAY BE
RETROSPECTIVE DATA FROM THE SWAN
STUDY LOOKING AT INDIVIDUALS WHO
HAVE HYPERTENSIVE DISORDERS OF
PREGNANCY, HAVING WORSE
CARDIOMETABOLIC HEALTH AROUND
THE PERIMENOPAUSAL TRANSITION,
BUT I DO THINK THE NEW MOM TO BE
HEART HEALTH STUDY, NOT JUST
BIASED BECAUSE I WORK WITH THEM,
IS REALLY VERY WELL POSITIONED
RIGHT NOW AS MANY OF THOSE
INDIVIDUALS ARE ABOUT TO
TRANSITION AND GO THROUGH THAT
PERIMENOPAUSAL PERIOD, HAVING
HAD FOLLOW-UP FROM THEIR FIRST
PREGNANCY SO BEING ABLE TO
REALLY START THEM AT A
MEASUREMENT OF CARDIOVASCULAR
HEALTH AT THAT FIRST PERIOD WITH
RIGOROUS ADJUDICATION OF ADVERSE
PREGNANCY OUTCOME STATUS AND NOW
COMING INTO THAT TRANSITION.
SO I THINK THAT COHORT IS REALLY
GOING TO TEACH US A LOT FOR THE
QUESTIONS YOU'RE ASKING.
>> WONDERFUL.
AND YOU READ MY MIND, I ALSO HAD
NEW MOM TO BE IN MY PURVIEW.
CAN YOU REMIND THE AUDIENCE THE
AGE AND SORT OF THE -- WHEN WE
MIGHT EXPECT TA THAT TYPE OF
RESEARCH CAN BE DONE
SPECIFICALLY IN THE NEW MOM TO
BE COHORT?
>> YEAH, THAT'S A GREAT
QUESTION.
I THINK THE MEAN AGE RIGHT NOW
FOR THE NEW MOM TO BE HEART
HEALTH STUDY PARTICIPANTS IS
SOMEWHERE AROUND 35 TO 40.
AND WE WOULD EXPECT MOST
INDIVIDUALS TO TRANSITION TO
MENOPAUSE SOMEWHERE BETWEEN 55
TO 60, ALTHOUGH PREMATURE
MENOPAUSE, I THINK TO HIGHLIGHT
YOUR POINT, OCCURRING EITHER
BEFORE 40 OR BEFORE 45, HAS ALSO
BEEN HIGHLIGHTED AS A
RISK-ENHANCING FACTOR FOR
CARDIOVASCULAR DISEASE, SO WE'RE
NOT THAT FAR AWAY FROM TRACKING
AND LOOKING AT THIS AND I KNOW
THEY ARE COLLECTING INFORMATION
ON PREGNANCY -- FOLLOW-UP
PREGNANCIES AS WELL AS ANY
MENOPAUSAL SYMPTOMS THAT MAY BE
COMING IN TERMS OF PERIOD
IRREGULARITY.
>> THANK YOU.
SO I SEE WE HAVE SEVERAL
QUESTIONS FROM THE AUDIENCE.
THE FIRST ONE, WHAT ROLE DOES
CVD SCREENING PLAY IN ENSURING
PATIENTS KNOW THEIR CVD STATUS?
AND DO YOU KNOW OF ANY VALIDATED
AND RECOMMENDED SCREENING TOOLS
WE SHOULD INCORPORATE INTO OUR
PERIPARTUM VISITS?
>> YEAH, I THINK THAT'S A GREAT
QUESTION.
AND DEFINITELY AN AREA WHERE
HAVING GUIDELINES THAT ARE
SPECIFIC TO EXACTLY WHEN AN
INDIVIDUAL SHOULD HAVE
CARDIOVASCULAR DISEASE SCREENING
AFTER PREGNANCY COULD BE REALLY
HELPFUL.
RIGHT NOW, THE GENERAL GUIDANCE
OR RECOMMENDATION IS AFTER THAT
3 TO 6 MONTH POSTPARTUM PERIOD
TO CONSIDER AN ASSESSMENT OF
CARDIOVASCULAR DISEASE RISK
FACTORS AND I THINK THE LIFE'S
ESSENTIAL EIGHT CARDIOVASCULAR
HEALTH FRAMEWORK IS A GREAT WAY
TO APPROACH THAT TO CONSIDER
WHAT SOMEONE'S CARDIOVASCULAR
HEALTH SCORE IS AND GOING
THROUGH AND ASSESSING THAT AS A
WAY TO MEASURE CARDIOVASCULAR
HEALTH AND THINK ABOUT
INTERVENTIONS TO THEN IMPROVE
CARDIOVASCULAR HEALTH.
THE PREVENT RISK SCORE IS
ANOTHER WAY TO THINK WITH
PREDICTED RISK THAT CAN ALSO BE
DONE FOR ADULTS 30 AND OLDER.
>> GREAT, THANK YOU.
WHY OR HOW DO YOU THINK
LACTATION IS RELATED TO IMPROVED
CARDIOMETABOLIC HEALTH OTHER
THAN THROUGH WEIGHT LOSS
POSTPARTUM?
>> YEAH, I THINK THAT'S A GREAT
QUESTION IN TERMS OF WHAT ARE
THE MECHANISMS THROUGH WHICH
LACTATION CAN IMPROVE
CARDIOMETABOLIC HEALTH AND I
THINK A LARGE PART OF IT IS
THROUGH THE ENERGY EXPENDITURE
THAT MAY BE RELATED TO WEIGHT
LOSS AND PARTICULARLY ACHIEVING
PREPREGNANCY WEIGHT, BECAUSE WE
KNOW THAT INDIVIDUALS WHO ARE
NOT ABLE TO RETURN TO THEIR
PREPREGNANCY WEIGHT OR HAVE
WEIGHT GAIN POSTPARTUM ARE MUCH
MORE LIKELY TO DEVELOP
HYPERTENSION AND DIABETES IN
THAT POSTPARTUM PERIOD.
>> GREAT.
YOU TOUCHED ON THIS A LITTLE BIT
ALREADY, BUT ARE THERE ANY
VALIDATED MEASURES FOR
CARDIOMETABOLIC DISEASE THAT WE
SHOULD USE TO TRACK A PATIENT'S
PROGRESS AND HAS LIFE'S
ESSENTIAL 8 BEEN USED FOR THAT
PURPOSE, BEEN VALIDATED FOR THIS
PURPOSE?
>> THAT'S A GREAT QUESTION.
I THINK THE LIFE'S ESSENTIAL
8 SCORE IS A GREAT ONE TO ANCHOR
ON BECAUSE IT HELPS TO CREATE A
COMPOSITE SCORE AROUND THE
CARDIOMETABOLIC FACTORS.
THE CARDIOVASCULAR KIDNEY
METABOLIC CONSTRUCT THAT I
INTRODUCED AT THE END REALLY
INTEGRATES THE LIFE'S ESSENTIAL
8 IN CARDIOVASCULAR HEALTH SCORE
WITH QUANTITATIVE RISK SCORING
FROM PREVENT TO ALLOW A MORE
QUALITATIVE STAGING APPROACH,
WITH YOU MAY BE CONSIDERED, BUT
I THINK RIGHT NOW, WE HAVE MUCH
MORE DATA ON THE LIFE'S
ESSENTIAL 8 SCORING APPROACH.
>> GREAT.
LET'S SEE.
ONE AUDIENCE MEMBER STATED THANK
YOU FOR A WONDERFUL LIFE COURSE
DISCUSSION AROUND PREGNANCY AND
PREGNANCY OUTCOMES.
WHAT DO YOU FEEL IS THE MOST
PROMISING INTERVENTION DURING
THE PREPREGNANCY OR
INTERPREGNANCY PERIODS TO
PREVENT OR REDUCE RISK FOR LONG
TERM CARDIOVASCULAR HEALTH IN
WOMEN WHO EXPERIENCE APOs
DURING PREGNANCY?
WOULD THIS INCLUDE MEDICATIONS,
ESSER SEISE, DIET OR ANYTHING
ELSE?
>> IT'S A REALLY, REALLY TOUGH
QUESTION, AND I THINK THE ANSWER
IS PROBABLY COMPLICATED AND
PERHAPS ONE OF THE THINGS THAT
MAY BE MOST HELPFUL IS THINKING
ABOUT A BIT OF A PRECISION
APPROACH WITH THIS QUESTION.
SO ARE THERE STRATEGIES THAT MAY
BE MORE TAILORED TO SPECIFIC
INDIVIDUALS THAT COULD HELP WITH
THIS, AND I THINK ABOUT
INDIVIDUALS WHO HAVE MAYBE
SIGNAL OF ELEVATED BLOOD
PRESSURE AND THINKING ABOUT LOW
SODIUM DIET INTERVENTION AND
PHYSICAL ACTIVITY INTERVENTION
VERSUS AN INDIVIDUAL WHO MAYBE
HAS SEVERE OBESITY AND ARE THERE
MEDICATIONS PARTICULARLY AS WE
LEARN MORE ABOUT GLUCAGON
RECEPTOR PEPTIDE ONE AGONISTS AS
A POTENTIAL APPROACH FOR
CONSIDERING EARLIER INTERVENTION
OR SHORT TERM USE IN THE SETTING
OF SEVERE OBESITY.
SO I THINK REALLY GOOD QUESTION,
AND PERHAPS ONE WHERE WE REALLY
NEED TO FOCUS A LOT OF THOUGHT
IN TERMS OF HOW WE WOULD EVEN
DESIGN THESE TYPES OF TRIALS
GIVEN THE CHALLENGE OF
IDENTIFYING PRE-PREGNANT
INDIVIDUALS AND THEN CONSIDERING
HOW WE WOULD MACH TRIAL DESIGN
WITH THE PHENOTYPE OF THE
INDIVIDUAL.
>> ANOTHER AUDIENCE MEMBER SAYS
GREAT PRESENTATION.
IT WAS FASCINATING TO SEE THE
GRAPH IN THE STUDY SHOWING THE
BURDEN OF YOUNGER GENERATIONS AE
HAVING.
DO YOU NOW STUDIES THAT EXPLORE
THE DIFFERENT RISK FACTOR BURDEN
AMONG GENERATIONS?
>> IT'S A GREAT QUESTION.
I THINK THERE'S BEEN KIND OF --
PERHAPS SOME OBSERVATIONAL
ANALYSES THAT COULD BE
CONSIDERED THINKING ABOUT THAT,
LIKE THE COLLABORATIVE PERINATAL
PROJECT OR CPP IS ONE THAT'S
FROM FIVE DECADES AGO, AND IF WE
COMPARE THAT TO SOME
CONTEMPORARY COHORTS TODAY, WE
MAY BE ABLE TO SEE SOME
PATTERNS.
ONE OF THE BIGGEST CHALLENGES IS
THAT DEFINITION OF SOME OF THESE
COMPLICATIONS HAS CHANGED OVER
TIME AS WELL.
IN MORE RECENT YEARS OR RECENT
GENERATIONS, I DON'T THINK THAT
THAT'S THE DRIVER, BUT WE REALLY
NEED LONGITUDAL OBSERVATIONAL
DATA THAT ALLOW US TO FOLLOW THE
SAME INDIVIDUAL TO BETTER
UNDERSTAND IF THOSE RISK FACTOR
CHANGES ARE WHAT ARE ASSOCIATED
WITH INCREASING RISK.
>> GREAT.
SOMEONE HAS RAISED THE QUESTION
AROUND TOBACCO, THIS IS GREAT.
THEY SAY GREAT TALK.
CAN YOU COMMENT ON THE ROLE OF
SMOKING, TOBACCO CESSATION IN
THE EARLY PREVENTION OF
CARDIOVASCULAR HEALTH IN MOTHERS
AND CHILDREN?
>> YEAH, I THINK THIS IS A GREAT
QUESTION AND ONE WHERE WE'VE HAD
A LOT OF SUCCESS IN TERMS OF
TOBACCO CESSATION AND NOW
PERHAPS WITH VAPING AND
E-CIGARETTES, WE'RE SEEING AN
INCREASING PREVALENCE AGAIN IN
YOUNG ADULTS OF USE OF TOBACCO
OR E-CIGARETTE PRODUCTS.
WE KNOW THOSE ARE ASSOCIATED
WITH POOR CARDIOVASCULAR HEALTH
AND I THINK WE'RE STILL
GENERATING EVIDENCE IN TERMS OF
UNDERSTANDING SPECIFICALLY FOR
TOBACCO AND MARIJUANA USE AND
OTHER E-CIGARETTES THE EXACT
IMPACT ON CARDIOVASCULAR HEALTH
FOR BIRTHING INDIVIDUALS AND
OFFSPRING, BUT I THINK THIS IS A
REALLY IMPORTANT AREA OF
RESEARCH.
>> I THINK WE HAVE TIME FOR ONE
QUICK QUESTION.
IN THE RESEARCH YOU MENTIONED,
IS CAROTID ULTRASOUND USED FOR
ALL PREGNANT PEOPLE OR ONLY
THOSE WITH CARDIOVASCULAR
SYMPTOMS DURING PREGNANCY?
>> GREAT QUESTION.
SO THAT ANCILLARY STUDY IS BEING
DONE IN THE NEW MOM TO BE HEART
HEALTH STUDY, AND I SEE A
QUESTION DESCRIBING THIS, SO
THIS WAS A STUDY WHERE 10,000
INDIVIDUALS WERE FIRST RECRUITED
IN 2010 IN THE FIRST TRIMESTER
OF THEIR PREGNANCY ACROSS EIGHT
SITES IN THE UNITED STATES.
AT ABOUT TWO TO SEVEN YEARS,
4,000 OF THEM WERE THEN
RE-EXAMINED, AND NOW THERE'S A
SECOND IN-PERSON VISIT THAT'S
HAPPENING WHERE EVERYONE WHO WAS
PART OF THAT COHORT IS BEING
INVITED TO HAVE A CAROTID
ULTRASOUND WITH THE GOAL TO THEN
BE ABLE TO EXAMINE THE
ASSOCIATION BETWEEN ADVERSE
PREGNANCY OUTCOMES AND THEIR
VASCULAR INJURY OR POTENTIAL FOR
INJURY AND ATHEROSCLEROSIS
TODAY.
>> WONDERFUL.
WELL, THANK YOU ALL TO EVERYONE
WHO JOINED US TODAY AND DURING
THE ONPA SEMINARS THIS YEAR.
COULD WE PLEASE BRING UP THE
LAST TWO SLIDES?
GREAT.
SO WE WILL BE BACK ON
SEPTEMBER 9TH AT 11:00 A.M.
EASTERN TIME, WHEN DR. KARYN
ESSER WILL PRESENT ON CIRCADIAN
CLOCKS AND EXERCISE, PARTNERS IN
HEALTH, OPEN TO THE PUBLIC
THROUGH NIH VIDEOCAST.
IF YOU HAVE ANY SUGGESTIONS FOR
TOPICS OR SPEAKERS YOU WOULD
LIKE TO HEAR, FEEL FREE TO EMAIL
THEM TO ONPA@MAIL.NIH.GOV.
THANK YOU AGAIN DR. KHAN FOR
SHARING YOUR INSIGHTS ON THIS
IMPORTANT TOPIC.
HAVE A GREAT REST OF THE DAY,
EVERYONE!
>> THANK YOU.