REVIEWS

women's health
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Hypertensive Disorders of Pregnancy and
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33 Risk of Future Cardiovascular Disease in
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Q1
Women
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Q15 Farnoosh Asghar Vahedi, Leila Gholizadeh & Mehrdad Heydari
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39 ABSTRACT: Cardiovascular disease continues to be the leading cause of mortality in women globally. In addition to traditional risk factors,
40 some sex-specific conditions increase the burden of cardiovascular disease in women. With this literature review, we aimed to review evi-
41 dence on associations between hypertensive disorders of pregnancy and risk of cardiovascular disease in later life. After a database search
and application of inclusion and exclusion criteria, 11 studies were included in the review. Our findings suggest that a history of preeclampsia,
42
gestational hypertension, or elevated systolic blood pressure alone during pregnancy is consistently associated with increased risk of
43 developing and dying from myocardial infarction, heart failure, hypertension, and/or stroke in later life. Nurses and other health care providers
44 should be aware of the cardiovascular risk associated with hypertensive disorders of pregnancy and engage women at risk in discussions
45 about health promotion strategies and interventions to address modifiable cardiovascular disease risk factors.
46 doi: 10.1016/j.nwh.2020.02.001 Accepted January 2020

47 KEYWORDS: cardiovascular disease, gestational hypertension, hypertensive disorders of pregnancy, nursing practice, preeclampsia, risk
Photo ª FatCamera / iStockphoto.com

48 factor
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51

C
ardiovascular disease (CVD) is the leading cause of accounts for one third of all deaths among women, and those
52 death; every year, 17.9 million people die from CVD who develop CVD are more likely to die from it if they live in
53 worldwide. Deaths from CVD globally increased by low- and middle-income countries (World Heart Federation,
54 14.5% between 2006 and 2016 (Benjamin et al., 2019). 2017). It is estimated that 45.1% of the population in the
55 According to the World Heart Federation (2017), CVD United States will have some form of CVD by 2035 (Benjamin

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56 Conditions such as a history of

57 CLINICAL IMPLICATIONS
58 polycystic ovary syndrome,
n Cardiovascular disease (CVD) continues to be the leading cause
59 of mortality in women globally. gestational diabetes, intrauterine
60 n The results of this review indicate that that a history of
61 preeclampsia, gestational hypertension, or elevated systolic
growth restriction, preterm birth,
62 blood pressure alone during pregnancy is consistently associated gestational hypertension, and
with increased risk of developing and dying from myocardial
63 miscarriage have been found to be
infarction, heart failure, hypertension, and/or stroke in later life.
64
65
n Women at increased risk of CVD, including those with history of associated with increased risk of
hypertensive disorders of pregnancy, need screening,
66 assessment, and support to reduce their future CVD risk through CVD in women
67 targeting modifiable risk factors.
68 n Nurses and other health care professionals can educate and
We aimed to collect and review evidence on associations
69 counsel women about CVD risk factors and risk management between hypertensive disorders of pregnancy (HDP) and
70 strategies. women’s risk of developing CVD in later life. HDP include
71 n Women should be actively engaged in risk prevention programs, chronic hypertension, preeclampsia, chronic hypertension
72 including adopting a healthful lifestyle and adhering to evidence- with superimposed preeclampsia, gestational hypertension,
based recommendations about diet, alcohol consumption, eclampsia, and postpartum hypertension. In 2013, the
73 exercise, medications, and regular check-ups for blood pressure,
74 American College of Obstetricians and Gynecologists (ACOG)
blood sugar, and blood cholesterol.
75 updated its definitions of different types of HDP (ACOG,
76 2013). According to ACOG, chronic hypertension is blood
et al., 2019), and the total costs and direct medical costs of pressure of 140/90 mmHg or greater detected after
77
CVD are expected to reach $1.1 trillion and $748.7 billion, conception or before 20 weeks of pregnancy; gestational hy-
78
respectively, by 2035 in the United States (Benjamin et al., pertension is new-onset elevation of blood pressure of 140/
79
2019). Thus, CVD continues to impose major financial 90 mmHg or greater, closer to term and in the absence of
80
burdens on health care systems. proteinuria; and preeclampsia is defined as blood pressure of
81
CVD generally refers to any disease that affects the cardio- 140/90 mmHg or greater in two separate measurements, at
82
vascular system and includes, but is not limited to, coronary least 4 hours apart, after 20 weeks of pregnancy, in those
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heart disease (CHD) and cerebrovascular disease (stroke). The pregnant women whose blood pressure was previously
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terms CHD, ischemic heart disease, and coronary artery dis- normal. Last, superimposed preeclampsia is chronic hyper-
85
ease refer to narrowing or blockage of the coronary arteries, tension in association with preeclampsia (ACOG, 2013). Pre-
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usually caused by atherosclerosis (Mosca et al., 2011). CHD is eclampsia itself is responsible for up to 15% of maternity-
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the leading cause of deaths from CVD; in the United States, related deaths (Funai et al., 2005), and occurs in 7.5% of all
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43.8% of all CVD-related deaths are attributable to CHD alone pregnancies; however, the incidence rate is lower in devel-
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(Benjamin et al., 2019). oped countries (2%–5%) than in developing countries (Brown
90
In addition to traditional CVD risk factors that contribute to et al., 2013).
91
development of CVD in both sexes, a number of risk factors
92
affect CVD risk in women only (Leening et al., 2014). Condi-
93
tions such as a history of polycystic ovary syndrome
94 Literature Review
(Mahendru & Morris, 2013), gestational diabetes, intrauterine
95
growth restriction (Rich-Edwards, Fraser, Lawlor, & Catov, Search Strategy
96
2013), preterm birth, gestational hypertension, and miscar-
97 The literature on associations between HDP and CVD was
riage (Cusimano, Pudwell, Roddy, Cho, & Smith, 2014) have
98 accessed by using predetermined search terms in MEDLINE
been found to be associated with increased risk of CVD in
99 and CINAHL. The search terms for exposure included hyper-
women.
100 tensive pregnancy disorders, hypertension, pregnancy-induced
101 hypertension, gestational hypertension, hypertensive disorders
102 of pregnancy, preeclampsia, pre-eclampsia, postpartum hy-
103 Farnoosh Asghar Vahedi, BSc, MSc, RM, is a PhD candidate at the Faculty of
pertension, eclampsia, and pregnancy complications. The
104 Health, University of Technology Sydney, in Sydney, New South Wales, search terms for outcomes included cardiovascular disease,
105 Australia. Leila Gholizadeh, PhD, MSc, BSc, RN, is a lecturer and member of heart disease, coronary heart disease, coronary artery dis-
106 Q2 IMPACCT at the Faculty of Health, University of Technology Sydney, in Sydney, ease, myocardial infarction, acute coronary syndrome,
New South Wales, Australia. Mehrdad Heydari, PhD, DVM, RN, is a casual
107 ischaemic heart disease, and ischemic heart disease. All pri-
academic at Faculty of Health, University of Technology Sydney in Sydney,
108 New South Wales, Australia. The authors report no conflicts of interest or
mary studies that examined associations between HDP and
109 relevant financial relationships. Address correspondence to: leila. the risk of developing CVD in later life were included. The
110 gholizadeh@uts.edu.au. search was limited to articles published from January 2000

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111 through December 2016. There was no limitation on the [CI] [1.1, 1.7]), ischemic heart disease (hazard ratio ¼ 1.36;
112 follow-up period. Non-English literature and review studies 95% CI [1.01, 1.83]), heart failure (hazard ratio ¼ 1.6; 95% CI
113 were excluded. Conference abstracts, letters to the editor, [1.1, 2.5]), and arterial hypertension (hazard ratio ¼ 2.33;
114 and editorial articles were also excluded. However, the refer- 95% CI [1.88, 2.88]). The risks of developing myocardial
115 ence lists of the included studies and excluded previous re- infarction (hazard ratio ¼ 1.2; 95% CI [0.73, 2.0]), experi-
116 view studies were checked for possible additional studies. encing death from myocardial infarction (hazard ratio ¼ XX; Q4
117 95% CI [0.51, 4.08]), and developing ischemic cerebrovas-
118 Study Selection cular disease (hazard ratio ¼ 1.19; 95% CI [0.68, 2.09]) also
119 A total of 314 publications were retrieved from the initial increased but were not statistically significant. These risks Q5
120 search. After limiting results to studies published in English were particularly greater if women had superimposed pre-
121 language and during the defined years of publication, the eclampsia/eclampsia or chronic arterial hypertension and
122 search yielded 248 citations. Review articles and duplications then developed preeclampsia/eclampsia (Ma €nnisto€ et al.,
123 were removed, leaving 165 articles for further assessment. 2013).
124 Initial screening of the article titles and abstracts resulted in Likewise, authors of a population-based cohort study in
125 the exclusion of 55 articles. The full texts of the remaining Israel analyzed death rates among 37,061 women who gave
126 studies were reviewed for relevancy, resulting in the exclusion birth in Jerusalem between 1964 and 1976, with a median 30
127 of a further 99 articles (see Figure 1). years (range ¼ 24–36 years) of follow-up (Funai et al., 2005). Q6
128 The authors concluded that the relative death rate was 2.13
129 Quality Assessment (95% CI [1.8, 2.5], p < .001) greater in women who were
130 The remaining 11 articles were assessed for quality by using diagnosed with preeclampsia compared with women who had
131 the Critical Appraisal Skills Programme (2016). None of the normal blood pressure readings during their pregnancy, and
132 studies was assessed as being of poor quality (see deaths from CVD contributed most strongly to this increase
133 Supplemental Table S1). Therefore, all of the 11 studies were (Funai et al., 2005).
134 included in the review. Supplemental Table S2 provides a brief Researchers conducting a large population-based cohort
135 summary of the included studies. study in Taiwan recruited 1,132,064 women who had given
136 birth between 1999 and 2003, through the linkage between
137 Resulting Themes birth certificates and national health insurance hospital
138 The reviewed studies were primarily large population-based discharge data (Lin et al., 2011). The authors aimed to
139 cohort studies that examined the risk of CVD events and/or investigate the risk of major CVD events and mortality during
140 mortality in women with a history of HDP (n ¼ 3,564,442). pregnancy and within 3 years postpartum. After adjusting for
141 There was one case–control study (n ¼ 629), and there was known CVD risk factors, they found that the risk of major
142 one cross-sectional population-based study (n ¼ 403,550). cardiac events and mortality were significantly greater in
143 Out of the included articles, nine studies were conducted in women with a history of preeclampsia/eclampsia, who had
144 Europe (three in Finland, two in Norway, and one each in 13.0 times greater risk of developing myocardial infarction
145 Iceland, Sweden, Scotland, and Denmark), one in Israel, and (95% CI [4.6, 6.3], p < .0001) and 8.3 times greater chance
146 one in Taiwan. The findings of this review are presented under of developing heart failure (95% CI [4.2, 16.4], p < .0001) in
147 Q3 the following four themes. later life. The risk of stroke was 14.5 times greater in these
148 women (95% CI [1.3, 165.1], p < .03), and participants had
149 Preeclampsia and Risk of CVD 6.4 times greater incidence of overall death (95% CI [3.8, Q7

150 The association between history of preeclampsia and risk of 10.9], p < .0001) and 2.3 times greater incidence of CVD-
151 CVD in women was examined in five studies (Arnadottir, related death (95% CI [1.6, 3.1], p < .0001) compared with
152 Geirsson, Arngrimsson, Jonsdottir, & Olafsson, 2005; Irgens, those without this condition (Lin et al., 2011). These results
153 Roberts, Reisæter, Irgens, & Lie, 2001; Lin et al., 2011; correspond with the findings of Funai et al. (2005), who re-
154 Ma€nnisto€ et al., 2013; Smith, Pell, & Walsh, 2001). Re- ported significantly greater death from CVD in women with a Q8
155 searchers conducting a population-based prospective cohort history of preeclampsia.
156 study recruited 12,055 multiparous women who had given Researchers in Scotland conducting a retrospective
157 birth in 1966 in Finland and followed the women for 40 years population-based cohort study recruited 129,290 women
158 (Ma€nnisto€ et al., 2013). The authors found that any form of from the Scottish Morbidity Record who had their first live
159 HDP was associated with increased risk of cardiac events and child between 1981 and 1985. The authors’ objective was to
160 diabetes in later life. According to this study, women with a examine the associations between preeclampsia and risk of
161 history of preeclampsia/eclampsia, compared with women future fatal and nonfatal CHD (Smith et al., 2001). Out of the
162 with normal blood pressure during pregnancy, were more likely cohort, 22,781 women developed preeclampsia during their
163 to develop CVD (hazard ratio ¼ 1.4; 95% confidence interval pregnancies, and 107,139 women did not. Following the
164
165

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166 FIGURE 1 LITERATURE SEARCH FLOW Authors of a registry-based cohort study in Denmark
167 DIAGRAM recruited 782,287 women from 15 to 50 years old who had
168 their first birth, with median follow-up of 14.60 years (Lykke
169 et al., 2009). The researchers found that the risk of devel-
Records identified through search
170 of databases oping CHD increased in women with a history of gestational
171 (n = 314) hypertension by 1.5 times (95% CI [1.25, 1.76], p < .001).
172 These women were also at greater risk of developing subse-
173 quent hypertension (5.3 times, 95% CI [4.90, 5.75], p <
174 .001) in the future (Lykke et al., 2009).
175 Records after applying search limits
Similarly, authors of a cohort study of 4,782 women from
(n = 248)
176 2,443 sibships (offspring who share the same two parents)
177 participating in the Family Blood Pressure Program study
178 between 2000 and 2004 in Finland reported that women with
179 Records after excluding review articles
a history of gestational hypertension were at greater risk for
180 and duplications developing hypertension in the future compared with their
181 (n = 165) normotensive counterparts (Garovic et al., 2010). The
182 increased risk remained significant after the authors
183 controlled for known CVD risk factors including race, family
184 Records after reviewing titles and history, smoking, dyslipidemia, and diabetes mellitus
185 abstracts (n = 110) (adjusted hazard ratio ¼ 1.8, 95% CI [1.4, 2.3], p < .001). In
186 addition, hypertension developed at earlier ages in these
187 Articles excluded due to seeking women (50% hypertensive at the age of 53 years vs. 60 years,
188 Records after reviewing full texts
different aims respectively; p < .001; Garovic et al., 2010). The relatively
(n = 39),
189 not meeting the inclusion criteria greater risk of future hypertension observed in the study by
(n = 11)
190 (n = 52), Lykke et al. (2009) may be due to the lack of complete ad-
191 or inappropriate study design justments for CVD risk factors, such as obesity (Lykke et al.,
(n = 8).
192 2009).
193 Studies assessed for quality Authors of a cross-sectional population-based study in
194 (n = 11) Sweden analyzed the risk of fatal or nonfatal CHD events in
195 403,550 women who had given birth between 1973 and
196 1982, with a follow-up of 15 years (Wikstro €m et al., 2005).
197 Studies included in the review They found that, compared with women with normotensive
(n = 11)
198 pregnancies, women with a history of gestational hyperten-
199 sion in their first pregnancy had an increased risk of devel-
200 oping CHD in later life (relative risk ¼ 1.6, 95% CI [1.3, 2.0];
201 Wikstro €m et al., 2005). A similar study was conducted in
women for 15 to 19 years, the researchers found that the rate
202 Iceland by Arnadottir et al. (2005), who recruited participants
of CHD events doubled (95% CI [1.5, 2.5]) in women who had
203 (n ¼ 325 case patients and n ¼ 650 individuals in the control
a history of preeclampsia when compared with the control
204 group) who had given birth at the University Hospital in Rey-
group (Smith et al., 2001). Authors of a similar population-
205 kjavik, Iceland, between 1931 and 1947, and followed them
based cohort study in Norway recruited 626,272 women
206 until 1996. They found that the risk of mortality from CHD
through the Norwegian Medical Birth Registry who had given
207 among women with a history of HDP was 24.3%, compared
birth from 1967 to 1992, with a median follow-up of 13 years
208 with 14.6% in women without the condition (relative risk ¼
(Irgens et al., 2001). They found that preeclampsia was
209 1.66, 95% CI [1.27, 2.17]; Arnadottir et al., 2005). These
associated with a 8.12-fold (95% CI [4.3, 15.3]) increased €m et al.
210 results are consistent with the findings of Wikstro
risk of death from CVD (Irgens et al., 2001).
211 (2005) and Garovic et al. (2010). Arnadottir et al. (2005)
212 reported that, overall, women with gestational hypertension
213 Gestational Hypertension and Risk of CVD survived 3 to 9 years less than women without this condition.
214 The relationships between gestational hypertension and risk Ma €nnisto
€ et al. (2013) also found that women with gesta-
215 of CVD in later life were examined in five studies (Arnadottir tional hypertension were at increased risk for CHD (hazard
216 et al., 2005; Lykke et al., 2009; Ma€nnisto
€ et al., 2013; ratio ¼ 1.44, 95% CI [1.24, 1.68]), myocardial infarction
217 Wikstro €m, Haglund, Olovsson, & Lindeberg, 2005). The re- (hazard ratio ¼ 1.75, 95% CI [1.40, 2.19]), death from
218 sults of these studies were consistent in finding positive as- myocardial infarction (hazard ratio ¼ 3.00, 95% CI [1.18,
219 sociations between the experience of gestational 3.09]), and ischemic stroke (hazard ratio ¼ 1.59, 95% CI
220 hypertension and CVD in later life. [1.24, 2.04]).

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221 pressure during early pregnancy, CVD mortality increased by

222 20%, and for one standard deviation increase in systolic
223 blood pressure in late pregnancy, the mortality rate
224 increased by 14% (Luoto et al., 2008). The authors
225 concluded that an increase in systolic blood pressure alone
226 during pregnancy could be considered as an important
227 predictor of future CVD risk and mortality in women (Luoto
228 et al., 2008). In another study, the risk of future ischemic
229 heart disease increased by 1.9 times (95% CI [1.6, 2.2]) in
230 women with mild preeclampsia compared with women
231 without the condition, but with a greater increase in women
232 with severe preeclampsia (relative risk ¼ 2.8, 95% CI [2.2,
233 €m et al., 2005).
3.7]; Wikstro
234
235
CVD Risk According to Order of Pregnancy,
236
237 Time of HDP Diagnosis, and Number of HDP
238 Diagnoses
239 Authors of a prospective population-based cohort study con-
240 The available evidence supports the ducted in Norway investigated the relationship between the
241 order of the pregnancy, time of onset of preeclampsia (pre-
242
view that pregnancy should be term or term), and mortality from CVD (Skjaerven et al.,
243 considered as a cardiovascular 2012). The researchers recruited 836,147 women from the
244 stress test, and the experience of Medical Birth Registry of Norway between 1967 and 2002 and
245 followed them until 2009. Of these women, 34,824 devel-
246 HDP indicates greater susceptibility oped preeclampsia during their pregnancy. The authors found
247 to CVD in the future that women who developed term preeclampsia in their first
248 pregnancy were more likely to die from CVD than those
249 Significance of Severity of HDP without the condition in their first pregnancy (adjusted hazard
250 The relationship between the severity of HDP and risk of future ratio ¼ 1.6, 95% CI [1.4, 2.0]; Skjaerven et al., 2012). This
251 CVD was assessed in three studies (Luoto et al., 2008; Lykke risk was even greater for women who developed preterm
252 €m et al., 2005), and these authors found
et al., 2009; Wikstro preeclampsia (adjusted hazard ratio ¼ 3.7, 95% CI [2.7, 4.8]).
253 that severity of HDP was a factor in increasing the risk. Lykke In addition, women who developed preterm preeclampsia in
254 et al. (2009) found that the risk of CHD increased by 1.57 their first pregnancy (<37 weeks) and did not have additional
255 times (95% CI [1.44, 1.72]) and 1.61 times (95% CI [1.34, children were at greater risk of CVD death compared with
256 1.94]) in women with mild preeclampsia and severe pre- women who had subsequent children (9.2% vs. 1.1%;
257 eclampsia, respectively, indicating no significant difference in Skjaerven et al., 2012). For women who had term pre-
258 future CHD risk according to the severity of preeclampsia after eclampsia and had only one child, the risk of death from CVD
259 a median of 14.60 years follow-up. However, compared with was 2.8%; this fell to 1.1% for those who had two or more
260 women with mild preeclampsia (relative risk ¼ 3.61, 95% CI children (Skjaerven et al., 2012). However, all-cause mortality
261 [3.43, 3.80]), those with severe preeclampsia were at greater for women with two or more lifetime births who had preterm
262 risk for developing hypertension in later life (relative risk ¼ preeclampsia in their first pregnancy did not increase
263 6.07, 95% CI [5.45, 6.77]; Lykke et al., 2009). (adjusted hazard ratio ¼ 1.1, 95% CI [0.87, 1.14]), even if
264 The impact of increased systolic blood pressure during they had preterm preeclampsia (Skjaerven et al., 2012). The
265 pregnancy, without specifying the type of HDP, on future results indicated that mortality from CVD was particularly
266 CVD risk was evaluated in a study in which authors derived greater in women with early preeclampsia in first pregnancy
267 data from a cohort of 4,090 women who gave birth between who did not have subsequent children (Skjaerven et al.,
268 1954 and 1963 in Finland, with a follow-up period of 2012).
Photo ª kali9 / iStockphoto.com

269 approximately 44 years (Luoto et al., 2008). Mortality data Including more than 20,000 women pregnant for the first
270 were gathered from the Finnish Cause-of-Death Registry. time and 2,000 women with recurrent HDP, Wikstro €m et al.
271 Results showed that CVD mortality rate was considerably (2005) reported that women with hypertensive disease in both
272 greater in women who had a history of systolic hypertension pregnancies had an increased hazard ratio of 2.8 (95% CI
273 during pregnancy, whether developed in early or late stages [2.0, 3.9]) compared with women with two healthy pregnan-
274 of pregnancy. For each 13  1 mmHg rise in systolic blood cies (Wikstro€m et al., 2005).
275

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276 HDP and Risk of Future Stroke hypertension, high serum uric acid levels, high micro-
277 Authors of several studies examined the relationship between albuminuria, and high serum triglyceride levels, factors that
278 HDP and stroke, and they consistently found positive re- escalate the risk of CVD (Aykas et al., 2015; Valdiviezo et al.,
279 lationships between the experience of HDP and increased risk 2012). In addition, women with a history of gestational hy-
280 of stroke in later life (Arnadottir et al., 2005; Garovic et al., pertension or severe preeclampsia are more likely to develop
281 2010; Lin et al., 2011; Lykke et al., 2009; Ma €nnisto € et al., Type 2 diabetes, which is a strong risk factor for developing
282 2013). In their population-based prospective cohort study in CVD in women (Lykke et al., 2009).
283 Finland, Ma €nnisto€ et al. (2013) found that gestational hyper- Some authors have found that the damaging effects of HDP
284 tension increased the risk of future ischemic stroke (hazard on the vascular system remain for many years, which can
285 ratio ¼ 1.59, 95% CI [1.24, 2.04]; Ma €nnisto
€ et al., 2013). dispose women to subsequent CVD (Valdiviezo et al., 2012).
286 Authors of a population-based cohort study in Taiwan found Ehrenthal, Rogers, Goldstein, Edwards, and Weintraub (2015)
287 that women with a history of preeclampsia or eclampsia had found that women with a history of preeclampsia had higher
288 14.5 times (95% CI [1.3, 165.1]) greater adjusted risk of blood pressures at 3 months and 1 year after the index compli-
289 developing stroke in the future, 7.3 times (95% CI [5.5, 9.7]) cated pregnancy compared with women without the complica-
290 greater chance of developing major adverse cardiovascular tion (Ehrenthal et al., 2015). If the increased blood pressure
291 events without stroke, and 2.3 times greater (95% CI [1.6, associated with preeclampsia or gestational hypertension re-
292 3.1]) chance of death from major adverse cardiovascular mains uncontrolled for years, the risk of coronary heart disease
293 events, compared with women without preeclampsia or increases by twofold (95% CI [1.86, 2.52]; Bellamy, Casas,
294 eclampsia (Lin et al., 2011). Hingorani, & Williams, 2007). Also, women with a history of
295 In addition, Lykke et al. (2009) found that the risk of stroke gestational hypertension or preeclampsia (mild or severe) are at
296 was elevated 1.51 times (95% CI [1.26, 1.81], p < .001) in greater risk for developing hypertension in later life (Garovic
297 women with history of gestational hypertension, 1.4 times et al., 2010; Lykke et al., 2009). This can partially explain the
298 Q9 (95% CI [1.30, 1.58]) in women with mild preeclampsia, and increased risk of stroke among these women (Ehrenthal et al.,
299Q10 1.58 times (95% CI [1.23, 2.03], p < .001) in women with 2015; Garovic et al., 2010; Lykke et al., 2009). Women who
300 severe preeclampsia, again indicating that the severity of HDP develop HDP early in pregnancy have a poorer CVD risk factor
301 is a concern (Lykke et al., 2009). Consistent with these re- profile than women who experience these conditions later in
302 sults, Arnadottir et al. (2005) found that the rate of death from their pregnancy (Veerbeek et al., 2015). It seems that the
303 cerebrovascular event including stroke was 9.5% in women increased vascular resistance seen in early preeclampsia can
304 with a history of HDP compared with 6.5% in women without lead to systolic and diastolic dysfunction and could be the
305 the condition (relative risk ¼ 1.46, 95% CI [0.94, 2.28]; possible mechanism in the development of chronic hypertension
306 Arnadottir et al., 2005). (Sibai et al., 1998; Veerbeek et al., 2015).
307 Furthermore, Canti et al. (2010) found that women with
308 preeclampsia had significantly greater body mass index (p ¼
309 Discussion .019) and abdominal circumference measurements (p ¼ .026)
310 The findings of this literature review suggest that a history of compared with normotensive pregnant women (Canti et al.,
311 any type of HDP is associated with increased risk of future 2010). It is well known that obesity, particularly increased waist
312 CVD events and mortality in women. The findings indicate that circumference, can escalate the risk of CVD (de Simone et al.,
313 women with a history of preeclampsia, gestational hyperten- 2006). Apart from the significant synergistic effects between Q11
314 sion, and/or elevated systolic blood pressure alone during HDP conditions and the known CVD risk factors, HDP has been
315 pregnancy are at greater risk for morbidity and mortality from shown to contribute to the risk of CVD in women independently
316 myocardial infarction, heart failure, hypertension, and stroke (Garovic et al., 2010; Lin et al., 2011; Ma €nnisto € et al., 2013;
317 in later life (Luoto et al., 2008; Lykke et al., 2009; Ma€nnisto
€ €
Skjaerven et al., 2012; Wikstrom et al., 2005)
318 et al., 2013). The evidence suggests that HDP adds to the The available evidence supports the view that pregnancy
319 burden of CVD in women; however, because of the heteroge- should be considered as a cardiovascular stress test, and the
320 neity across the reviewed studies in terms of population, experience of HDP indicates greater susceptibility to CVD in
321 exposure variables, outcome variables, and follow-up periods, the future (Hermes et al., 2013; Veerbeek et al., 2015). This
322 it was difficult to combine the results statistically in a meta- knowledge provides an opportunity for early identification of
323 analysis to derive a pooled estimate of the impact of HDP these high-risk women and to provide them with education
324 conditions on CVD risk. and counseling to help them adopt healthful behaviors and
325 Although the underlying mechanisms linking HDP to engage in a risk-reducing strategy.
326 increased risk of CVD are not very well understood (Aykas
327 et al., 2015; Garovic et al., 2010; Lykke et al., 2009; Limitations
328 Valdiviezo, Garovic, & Ouyang, 2012), this association might The findings of this review should be interpreted with some
329 be due to some shared risk factors between the two condi- caution. This review is limited by our ability to review the
330 tions. Women who experience HDP are more likely to have relevant literature in the specific time period of the research.

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331 pregnancy history when

332 assessing a woman’s CVD
333 risk. CVD risk assessment
334 tools, such as the Fra-
335 mingham risk score
336 (Selvarajah et al., 2014),
337 the SCORE score
338 (Selvarajah et al., 2014),
339 and the Reynolds risk score
340 (Ridker, Buring, Rifai, &
341 Cook, 2007) enable health
342 care providers to identify
343 high-risk population sub-
344 groups for close moni-
345 toring, early diagnosis, and
346 therapy (Lloyd-Jones,
347 2010). It has been shown
348 that the effects of HDP on
349 the cardiovascular system
350 are reflected in the existing
351 CVD risk estimation tools.
352 For example, in a longitudi-
353 nal follow-up study in The
354 Netherlands (Hermes
355 et al., 2013), in which re-
356 searchers used the Fra-
357 mingham Risk Score, the
358 estimated 10-year and 30-
359 year CVD risks of 300 women with a history of HDP were
360 Nurses have a vital role to play in compared with the estimated CVD risks of 94 women with
361 helping women with HDP normotensive pregnancies. After a mean follow-up of 2.5 years,
362 the estimated 10-year CVD risk of women with HDP was signifi-
363
understand and take action cantly greater than the risk of women who did not have the
364 regarding their risk for CVD later in condition (7.2% vs. 4.4%, respectively; p < .001, incident rate
365 ratio ¼ 5.8, 95% CI [1.9, 19]). The estimated 30-year CVD risk
life
366 was also greater in women with HDP than women without the
367 However, we believe that our search in MEDLINE and CINAHL condition (11% vs. 7.3%, respectively; p < .001, incident rate
368 retrieved the most recent large population-based cohort ratio ¼ 2.7, 95% CI [1.6, 4.5]). The results were consistent when
369 studies. We also appraised the quality of the included studies the SCORE score and the Reynolds Risk Score were applied
370 (see Supplemental Table S1) and ensured that the included (Hermes et al., 2013). Likewise, when comparing the estimated
371 studies were high-quality research. risk of CHD and stroke between women with and without a his-
372 tory of HDP, Garovic et al. (2010) found that women who had a
HDP may have been differently defined or misclassified in
373 €nnisto
€ et al. history of hypertension during pregnancy showed an increased
the included studies. For example, although Ma
374 estimated risk for CHD (14% vs. 11% at 70 years, respectively;
(2013) considered blood pressure of 145/95 mmHg or
375 p ¼ .009) and stroke (8% vs. 5% at 70 years, respectively; p ¼
greater with proteinuria as the definition of preeclampsia,
376 .009) compared with women without the condition (Garovic
Funai et al. (2005) used blood pressure of 140/90 mmHg or
Photo ª didesign021 / iStockphoto.com

377 et al., 2010).

greater and 1þ protein in urine on a dipstick as diagnostic
378 Because women of reproductive age are younger and may
criteria.
379 not manifest the symptoms of CVD for many years, the use of
380 appropriate CVD risk estimation tools is a pragmatic approach
381 Implications for Practice to identify high-risk women who can benefit from risk modifi-
382 The findings of this review have several implications for practice. cation interventions (Lloyd-Jones, 2010). However, the ability
383 The evidence highlights the importance of considering of the available tools to predict CVD risk is poorer in women
384
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386 than in men, particularly among younger women (Hermes et al., CVD risk associated with HDP and on identifying, imple-
387 2013; Wenger, 2017). It is suggested that future research menting, and evaluating strategies to close any knowledge
388 evaluate the possibility of improving the accuracy of existing gaps and improve the cardiovascular health outcomes for
389 CVD assessment tools for women by including women-specific women with a history of HDP.
390 risk factors, such as history of HDP. The pooled cohort equa-
391 tions (Goff et al., 2014), endorsed by the American College of Conclusion
392 Cardiology and American Heart Association, aim to improve
Women with a history of HDP are at significantly greater risk
393 CVD risk estimation for women by considering their greater
for developing CVD in later life. This knowledge should
394 lifetime CVD risk; however, overestimation of CVD risk with
encourage health care providers to identify this high-risk
395 advanced age is a concern with this tool (Wenger, 2017).
subgroup of women and offer them appropriate screening and
396 Efforts should also be made to increase awareness of the
counseling. These women should be encouraged to discuss
397 link between HDP and CVD among health care providers and
their cardiovascular health with health care providers and be
398 women with these conditions. Nurses can play an important
supported to reduce their future CVD risk through the adoption
399 role in increasing women’s awareness of cardiovascular
of a healthful lifestyle and recognition and improvement of
400 health and risk factors and encouraging women with a history
modifiable risk factors. Nurses have a vital role to play in
401 of HDP to discuss their cardiovascular health with a general
helping women with HDP understand and take action
402 practitioner or cardiologist (Berra, 2011). In its position
regarding their risk for CVD later in life. NWH
403 statement on women’s cardiovascular health, the Association
404 of Women’s Health, Obstetric and Neonatal Nurses (2011)
405 advised that nurses should provide women with regular car- Supplementary Material
406 diovascular health screening and education during health care Note: To access the supplementary material that accom- Q14

407 visits to foster their awareness of CVD risk factors. Increasing panies this article, visit the online version of Nursing for
408 women’s knowledge of CVD risk factors and helping them Women’s Health at http://nwhjournal.org and at https://doi.
409 develop a reasonable risk perception is important to facilitate org/10.1016/j.nwh.2020.02.001.
410 active engagement in risk-reducing behaviors (Gholizadeh,
411 Davidson, Salamonson, & Worrall-Carter, 2010). To achieve
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