Q&A: Long-Term Stroke Risk in Women With Prior Hypertensive Disorders of Pregnancy

The following article is part of conference coverage from the 2019 American Academy of Neurology Annual Meeting (AAN 2019) in Philadelphia, PA. Neurology Advisor’s staff will be reporting breaking news associated with research conducted by leading experts in neurology. Check back for the latest news from AAN 2019.

PHILADELPHIA — The long-term risk for stroke was higher in women with a history of hypertensive disorders during pregnancy, according to a study presented at the 2019 American Academy of Neurology Annual Meeting, held May 4 to 10, 2019, in Philadelphia, Pennsylvania.¹

Eliza C. Miller, MD, assistant professor of neurology in the Division of Stroke and Cerebrovascular Disease at New York-Presbyterian and Columbia University Irving Medical Center in New York City presented the results from her clinical trial, “Aspirin Reduces Long-Term Stroke Risk in Women With Prior Hypertensive Disorders of Pregnancy,²” during the Stroke Prevention Strategies Scientific Session.

Dr Miller and colleagues sought to determine whether hypertensive disorders of pregnancy increased the long-term risk for stroke in women. In addition, they observed whether statin or aspirin use modified this risk. Participants were enrolled from the California Teacher Study who were aged ≤60 years at the time of enrollment in 1995. Investigators found that women with a history of hypertensive disorders of pregnancy had an increased risk for all stroke (adjusted hazard ratio, 1.3; 95% CI, 1.2-1.4). Dr Miller and colleagues also found that there was an association between aspirin use and history of hypertensive disorders of pregnancy before the age of 60. Women who did not use aspirin before the age of 60 had a higher risk for stroke compared with those who did. No association was found between statin use and risk for stroke.

Neurology Advisor: How would you recommend clinicians screen patients with a history of pregnancy-related hypertensive disorders?

Eliza C. Miller, MD: Women should be identified at the time they have the disorder. Ideally, this is a great opportunity to intervene and initiate primary preventive strategies even if that strategy does not include a medication — unless they develop chronic hypertension, which many patients do. To make patients aware of their risk at the moment they are identified with a hypertensive disorder of pregnancy is a golden opportunity. Furthermore, taking history of hypertensive disorders of pregnancy should be a part of the general vascular history.

Clinicians in other fields, such as cardiologists, primary care providers, or internists, should ask about obstetric history. Many gynecologists serve as primary care physicians for women, and there is a need for a strong partnership so that the cardiovascular risk in these patients is identified. The American College of Obstetrics and Gynecology has become much more aware of this risk and they are looking to partner internists with neurologists and cardiologists to improve long-term cardiovascular health after pregnancy complications.

Neurology Advisor: Women who develop preeclampsia during pregnancy may have a higher risk of developing preeclampsia in subsequent pregnancies, in these patients, do you recommend that they follow-up with a neurologist or begin a low-dose aspirin as a method of primary prevention at an earlier age than patients who do not develop hypertensive disorders of pregnancy?

Eliza C. Miller, MD:  Women who have a history of prior preeclampsia are at a very high risk of developing recurrent preeclampsia. Because of this they fall into a high-risk group that is generally put on low-dose aspirin during their pregnancy for preeclampsia prevention for their subsequent pregnancy. In addition, monitoring the blood pressure closely is very critical.

Not everyone needs to be seen by a neurologist if they have a diagnosis of a hypertensive disorder during pregnancy. The subgroup of women who would benefit from seeing a neurologist would be those who have neurological symptoms or complications from their preeclampsia. This would include women who have severe headaches and migraines because there is a connection between migraine and preeclampsia. It is also important to be aware of stroke, posterior reversible encephalopathy syndrome, or cerebral vasoconstriction syndrome. This subgroup of patients could benefit from seeing a neurologist either during pregnancy or postpartum.

Neurology Advisor: In your study, one of the outcomes was that women who took aspirin before the age of 60 had a decrease risk for stroke. What patient population would you recommend would start a low-dose of aspirin before the age of 60 for primary prevention?

Eliza C. Miller, MD: This approach has to be individualized. I personally would not start a women on low-dose aspirin in her 30s if she has not had a neurological event. In a women who is >45 years of age or in her early 50s with vascular risk factors with a history of preeclampsia associated with preterm delivery, I do sometimes recommend a low-dose aspirin for primary prevention. In addition, I counsel patients about the associated risks of aspirin, such as bleeding, gastrointestinal bleeding, and even intracranial hemorrhage. Even more important than aspirin is maintaining good blood pressure control. In my opinion, this is the single most important thing that is often missed. Many women are unaware they have high blood pressure because it can be asymptomatic.

Dr. Miller concluded that “we have to do a better job at collaborating with our obstetrics and gynecology colleagues. There are so many opportunities for partnership and they are very interested in collaborating with us. I think that raising awareness of this issue among neurologists and getting into a more of a collaborative relationship with the [obstetrics] community is going to be beneficial for both specialties.”

For more coverage of AAN 2019, click here.

References

1. Miller EC. Aspirin reduces long-term stroke risk in women with prior hypertensive disorders of pregnancy. Presented at: 2019 American Academy of Neurology Annual Meeting; May 4-10, 2019; Philadelphia, PA. S35.
2. Miller EC, Boehme AK, Chung NT, et al. Aspirin reduces long-term stroke risk in women with prior hypertensive disorders of pregnancy. Neurology. 2019;92(4):e305-e316.