Hypertensive Disorders of Pregnancy: An Updated Review of Short- and Long-Term Cardiovascular Implications

Abstract

Hypertensive disorders of pregnancy (HDP) affect approximately 1 in 7 pregnancies in the United States and are increasingly recognized as early and independent markers of lifetime cardiovascular disease. This review provides an update of the evidence for classification, pathophysiology, and management of HDP with an emphasis on risk stratification, treatment, and the long-term cardiovascular consequences with suggested models for postpartum care transitions. Contemporary evidence supports a mechanistic link between the endothelial dysfunction that occurs in HDP and persistent vascular injury, supporting the observations that the greatest risk for cardiovascular complications occur outside of the traditional postpartum period. Remote blood pressure monitoring programs have emerged as a vital strategy, reducing morbidity and long-term hemodynamic benefit to extended surveillance for patients with HDP. Advances in prediction models to identify patients during pregnancy at risk of developing severe disease include incorporation of biomarkers such as the soluble fms-like tyrosine kinase-1 to placenta growth factor (sFlt-1/PlGF) ratio. However, risk prediction and stratification strategies for long-term consequences of HDP and prevention well after the pregnancy episode remain understudied. HDP presents short- and long-term cardiovascular risk that begins in the immediate postpartum period and persists across the lifespan. These risks, particularly in the long-term, are underrecognized and lack structured stratification tools. This represents a significant gap in care and opportunity to improve care for the pregnant and postpartum population. Closing this care gap requires structured, multidisciplinary, and equity-driven approaches that extend cardiovascular surveillance and prevention well beyond the traditional postpartum window.