Jennifer Lewey’s research while affiliated with Texas Heart Institute and other places

Hypertension in pregnancy contributes substantially to maternal morbidity and mortality, persistent hypertension, and rehospitalization. Hypertensive disorders of pregnancy are also associated with a heightened risk of cardiovascular disease, and timely recognition and modification of associated risk factors is crucial in optimizing long-term maternal health. During pregnancy, there are expected physiologic alterations in blood pressure (BP); however, pathophysiologic alterations may also occur, leading to preeclampsia and gestational hypertension. The diagnosis and effective management of hypertension during pregnancy is essential to mitigate maternal risks, such as acute kidney injury, stroke, and heart failure, while balancing potential fetal risks, such as growth restriction and preterm birth due to altered uteroplacental perfusion. In the postpartum period, innovative and multidisciplinary care solutions that include postpartum maternal health clinics can help optimize short- and long-term care through enhanced BP management, screening of cardiovascular risk factors, and discussion of lifestyle modifications for cardiovascular disease prevention. As an adjunct to or distinct from postpartum clinics, home BP monitoring programs have been shown to improve BP ascertainment across diverse populations and to lower BP in the months after delivery. Because of concerns about pregnant patients being a vulnerable population for research, there is little evidence from trials examining the diagnosis and treatment of hypertension in pregnant and postpartum individuals. As a result, national and international guidelines differ in their recommendations, and more studies are needed to bolster future guidelines and establish best practices to achieve optimal cardiovascular health during and after pregnancy. Future research should focus on refining treatment thresholds and optimal BP range peripartum and postpartum and evaluating interventions to improve postpartum and long-term maternal cardiovascular outcomes that would advance evidence-based care and improve outcomes worldwide for people with hypertensive disorders of pregnancy.

The use of assisted reproductive technology (ART) is growing, both to assist individuals with infertility and for fertility preservation. Individuals with cardiovascular disease (CVD), or risk factors for CVD, are increasingly using ART. Thus, knowing how to care for patients undergoing ART is important for the cardiovascular clinician. In this scientific statement, we review the ART process and known short-term and long-term risks associated with ART that can adversely affect patients with CVD. We review current knowledge on risks from ART for specific cardiac conditions and provide a suggested approach to evaluating and counseling patients with CVD contemplating ART as well as suggested management before and during the ART process. Individuals with CVD are at increased risk for pregnancy complications, and management of this unique population has been discussed previously. The focus of this scientific statement is on ART. Therefore, discussions on risk assessment, counseling, and management of individuals with CVD during pregnancy are limited, and established guidelines are referenced.

BACKGROUND Postpartum hypertension is a key factor in racial-ethnic inequities in maternal mortality. Emerging evidence suggests that experiences of racism, both structural and interpersonal, may contribute to disparities. We examined associations between gendered racial microaggressions (GRMs) during obstetric care with postpartum blood pressure (BP). METHODS We conducted a prospective postpartum cohort of 373 Asian, Black, and Hispanic people in New York City and Philadelphia. At delivery, we administered the GRM in obstetrics scale. We measured BP for 3 months using text-based monitoring. We estimated place-based structural racism with the Structural Racism Effect Index. We used mixed models to estimate associations between GRM and mean postpartum systolic BP and diastolic BP. We adjusted for race-ethnicity, education, body mass index, chronic hypertension (diagnosed at <20 weeks of gestation), age, and the Structural Racism Effect Index. We examined effect modification by hypertensive disorder of pregnancy and place-based structural racism. RESULTS A total of 4.6% of participants had chronic hypertension, 20.9% had pregnancy hypertension, and 13.4% had preeclampsia, comprising a hypertensive disorder of pregnancy subgroup (n=117). A total of 37.5% of participants experienced ≥1 GRM. Participants who experienced ≥1 GRM versus none had 1.88 mm Hg higher systolic BP from days 1 to 10 (95% CI, −0.19 to 3.95) and 2.19 mm Hg higher systolic BP from days 11 to 85 (95% CI, 0.17–4.22). Associations followed a similar pattern for diastolic BP and were stronger among the hypertensive disorder of pregnancy subgroup. Participants experiencing GRM and a high Structural Racism Effect Index had systolic BP 7.55 mm Hg (95% CI, 3.41–11.69) and diastolic BP 6.03 mm Hg (95% CI, 2.66–9.41) higher than those with neither. CONCLUSIONS Structural racism and interpersonal racism are associated with increased postpartum BP, potentially contributing to inequities in postpartum morbidity and mortality and lifecourse cardiovascular disease.

Importance Short sleep duration during pregnancy and the perimenopausal period has been associated with adverse cardiometabolic outcomes. However, it remains unclear how sleep duration changes after delivery and whether such changes are associated with the cardiometabolic health of birthing people. Objective To investigate whether persistently short sleep during pregnancy and after delivery is associated with incident hypertension and metabolic syndrome. Design, Setting, and Participants This secondary analysis of the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be Heart Health Study (NuMoM2b-HHS), an ongoing prospective cohort study, was conducted between September 5, 2023, and March 1, 2024, in 8 US academic medical centers. Participants were aged 18 years or older at NuMoM2b enrollment; recruited during their first pregnancy between October 1, 2010, and September 30, 2013; and followed up for a mean (SD) of 3.1 (0.9) years after delivery. Exposures Self-reported short sleep duration (<7 hours) during pregnancy and 2 to 7 years after delivery was defined as persistent short sleep. Main Outcomes and Measures Incident hypertension and metabolic syndrome (MetS) at follow-up. Regression models were used to estimate relative risks of incident hypertension and MetS by sleep duration pattern. Hypertension analyses excluded participants with hypertension at baseline, and MetS analyses excluded participants with MetS at baseline. Multivariable models included a priori covariates of baseline age and time from delivery to follow-up. Incident hypertension analyses included an additional covariate of body mass index at baseline. Results Among 3922 participants (mean [SD] age, 27.3 [5.4] years; 598 Hispanic [15.2%], 485 non-Hispanic Black [12.4%], and 2542 non-Hispanic White [64.8%]), 565 individuals (14.4%) experienced persistent short sleep. Non-Hispanic Black (adjusted odds ratio [aOR], 2.17; 95% CI, 1.59-2.97) and unmarried (aOR, 1.68, 95% CI, 1.29-2.19) participants were significantly more likely to experience persistent short sleep compared with non-Hispanic White and married participants, respectively. Persistent short sleep was associated with higher odds of incident MetS (aOR, 1.60; 95% CI, 1.21-2.11) but not incident hypertension (aOR, 0.91; 95% CI, 0.69-1.19). Conclusions and Relevance In this study, short sleep duration that persisted from pregnancy to 2 to 7 years after delivery was associated with a greater risk for adverse cardiometabolic outcomes. Future studies should explore whether sleep-targeted interventions during and after pregnancy are associated with improved cardiometabolic health outcomes, particularly among populations at increased risk.

Background Individuals have a higher risk of cardiovascular disease later in life if they give birth to a child with congenital heart disease (CHD). The mechanism of this association has not been well documented. Objectives The authors aimed to describe the prevalence of cardiovascular disease and risk factors in women and birthing individuals 18 to 23 years after delivery of a child with CHD compared to normative data. Methods A cross-sectional survey was distributed to mothers whose infants with CHD had undergone cardiac surgery in 1998 to 2003 and previously enrolled in a prospective observational study. We compared rates of cardiovascular disease and risk factors to age- and sex-matched parous women and birthing individuals from National Health and Nutrition Examination Survey. Results An attempt was made to contact 533 mothers; 222 (42%) completed the survey. The mean age was 52 years, 86% were White, and 69% completed college. Common cardiovascular risk factors were high cholesterol (32%), hypertension (27%), preterm delivery (32%), and hypertensive disorder of pregnancy (13%). Overall, 15.3% reported presence of cardiovascular disease as defined by atherosclerotic cardiovascular disease, heart failure, valvular disease, or arrhythmia. A higher severity of child’s CHD was significantly associated with self-reported maternal cardiovascular disease (P = 0.03). Compared to National Health and Nutrition Examination Survey participants, rates of atherosclerotic cardiovascular disease and cardiovascular risk factors were similar. Conclusions Women and birthing individuals whose children had CHD had similar rates of cardiovascular risk factors and disease at 18 to 23 years after delivery, compared to age- and sex-matched parous controls. Higher severity of child’s CHD was associated with increased risk of maternal cardiovascular disease, an association that should be evaluated in future studies.

Introduction: Serious mental illness (SMI) is associated with higher risk of immediate procedural complications after transcatheter aortic valve replacement (TAVR), including myocardial infarction, major bleeding, and acute renal failure. There is limited data on the impact of SMI on in-hospital mortality and 30-day readmissions. We aimed to evaluate access to and outcomes after TAVR for patients with SMI compared to those without SMI. Methods: We performed a retrospective cohort study of adults aged ≥18 years who received TAVR with a primary diagnosis of aortic stenosis using the Healthcare Cost and Utilization Project State Inpatient Database and State Ambulatory Surgery and Services Database in FL, MD, VT, UT, and WI (2016-2019). SMI was defined using ICD-10 codes for schizophrenia spectrum, mood, or anxiety disorders. Primary outcomes include in-hospital mortality, 30-day readmission, length of stay, and routine discharge. The secondary outcome was access type (elective vs. urgent/emergent). Multivariable logistic and negative binomial regression models with adjustment for patient demographics, co-morbidities, and hospital characteristics were used to examine outcomes. Results: Of 21,905 patients who underwent TAVR for aortic stenosis, 2,954 (13.5%) patients had SMI. Overall, 16,762 (76.5%) of patients had elective procedures. Patients with SMI were more likely to be female (59% vs. 41%, p<0.001) and have 3+ co-morbidities (91% vs. 77%, p<0.001) but had similar income quartile distribution (p=0.18), home-to-hospital distance (p=0.09), and clinically similar hospital TAVR volume over the study period (435 vs. 430, p=0.01). After adjustment for potential confounders, access to and outcomes of TAVR differed significantly by SMI status (See Table). Conclusions: SMI patients had increased odds of emergent access to TAVR. After TAVR, SMI patients had longer length of stay and were less likely to be discharged to home. These findings suggest increased discharge planning may be required for patients with SMI after TAVR and highlight the need for additional investigation into barriers to elective TAVR in this vulnerable population.

Background: Hypertensive disorders of pregnancy (HDP) are a leading cause of maternal morbidity and contribute to cardiovascular disease later in life. Early identification of patients at highest risk of HDP may improve targeting of preventive therapies. Prior work within the Kaiser Permanente Northern California (KPNC) cohort demonstrated that early pregnancy blood pressure trajectories (BPT) improved HDP prediction compared to clinical factors alone. Our objective is to assess the performance of BPT models in a racially diverse patient population. Methods: We identified patients within Penn Medicine with a delivery from 2012-2020 and ≥3 outpatient BP measurements between 0 to 20 weeks gestation. Patients with pre-existing hypertension (HTN) or serious medical conditions were excluded. Covariates were obtained from the electronic medical record (EMR). Each patient was assigned one of six BPT groups based on KPNC latent class growth models. The primary outcome of HDP diagnosis, including preeclampsia and gestational HTN, was identified using ICD codes. Multivariable logistic regression was used to model the relationship between patient factors and HDP diagnosis. Predictive models were compared using the C-statistic. Results: Among 26,430 patients, the mean age was 30.8 years, 23% had Medicaid insurance, and 32% identified as Black. Overall, 22% of patients developed HDP and incidence varied by BPT group (Figure). After adjusting for age, race/ethnicity, parity, BMI, and diabetes, the moderate-stable group (aOR 5.42, 95% CI 3.7-8.3) and the elevated-stable group (aOR 10.2, 95% CI 6.9-15.8) had the strongest associations with HDP compared to the ultra-low-declining group. The prediction model including patient factors and BPT groups had better discrimination for HDP compared to patient factors alone (C-statistic 0.71 vs 0.66). Overall, models including BPT groups performed similarly to those from the KPNC cohort. Conclusions: Compared to the KPNC cohort, the Penn cohort had higher prevalence of patients with HDP, who identified as Black and had Medicaid insurance. Despite these differences, early pregnancy BPT groups demonstrated a similar improvement in HDP prediction compared to patient risk factors alone.

Background: Hypertensive disorders of pregnancy (HDP), including preeclampsia and gestational hypertension, are associated with increased risk of cardiovascular disease (CVD) later in life. This effect is strongly mediated by the subsequent development of chronic hypertension (HTN). Our objective is to identify clinical factors associated with incident HTN in a racially diverse cohort of postpartum patients using electronic health record (EHR) data. Methods: We identified patients with a delivery at Penn Medicine between 2012 and 2020 who did not have chronic HTN prior to delivery. The primary outcome was HTN between 6 and 24 months postpartum. HTN was identified based on ≥1 ICD code or ≥2 blood pressures (BP) ≥140/90. Univariable and multivariable logistic regression was used to model the association between patient factors assessed during pregnancy through the 6-week postpartum visit and incident HTN. Results: In the final cohort of 34,074 unique patients, mean age was 29.6 years, 42% identified as Black, and 38% had Medicaid insurance. A total of 1,078 patients (3.2%) developed incident HTN between 6 and 24 months postpartum. HTN was more common in patients with HDP compared to those without HDP (8.6% vs. 1.6%, p< 0.001). Factors independently associated with HTN are listed in the Table. After adjusting for patient demographics and clinical factors, older maternal age, Black race (vs. White race), preterm birth, obesity, diabetes, HDP, and 6-week postpartum systolic BP (SBP) were associated with HTN. HDP (OR 3.8, 95% CI 3.2, 4.5) and pre-pregnancy BMI ≥35 kg/m2 (OR 2.2, 95% CI 1.8, 2.7) were associated with the highest odds of incident HTN. Every 1 mmHg increase in postpartum SBP was associated with a 6% higher odds of incident HTN, after adjusting for HDP and other clinical factors. Conclusions: Patient factors that are routinely collected in the EHR, including HDP and BMI, are strongly associated with increased risk of developing incident HTN between 6-24 months postpartum in a racially diverse cohort. SBP at 6-weeks postpartum is an independent and underappreciated risk factor for HTN. Future work will develop and validate prediction models of incident postpartum HTN in this population at risk for CVD.