Five-year cardiovascular outcomes across hypertensive disorders of pregnancy subtypes: a propensity-matched analysis

Laith Alhuneafat, Omar Obeidat, Dina Mohammed, Nikita Sumzin, Kamel Ikbariah, Ahmad Al‐Abdouh, Ahmad Jabri, Bhavadharini Ramu, Jessica Schultz, Jessica Gottula, Bethany A. Sabol, Selma Carlson

Background Hypertensive disorders of pregnancy (HDP) are established risk factors for future cardiovascular disease, yet long-term cardiovascular risk across specific HDP subtypes remains incompletely defined. Methods We conducted a retrospective cohort study using a large, global electronic health record network to evaluate five-year cardiovascular outcomes among women with gestational hypertension, chronic hypertension, preeclampsia/eclampsia, and superimposed preeclampsia compared with normotensive pregnancies. Propensity score matching was performed to balance baseline demographic and cardiometabolic risk factors. Outcomes included heart failure, ischemic heart disease, stroke, pulmonary embolism, atrial fibrillation or flutter, and major adverse cardiovascular events (MACE). Results After propensity score matching, 109,945 women with gestational hypertension, 36,560 with chronic hypertension, 94,198 with superimposed preeclampsia, and 80,848 with preeclampsia/eclampsia were each matched 1:1 with normotensive controls. Superimposed preeclampsia was associated with the largest observed odds of adverse cardiovascular outcomes, including heart failure (OR 3.80, 95% CI 3.46–4.16), stroke (OR 3.66, 95% CI 3.35–4.00), ischemic heart disease (OR 3.08, 95% CI 2.83–3.36), and MACE (OR 3.29, 95% CI 3.11–3.47). Chronic hypertension and preeclampsia/eclampsia demonstrated comparatively elevated risk, with chronic hypertension associated with increased odds of heart failure (OR 2.88, 95% CI 2.43–3.43) and MACE (OR 2.24, 95% CI 2.01–2.49), and preeclampsia/eclampsia associated with higher odds of heart failure (OR 3.10, 95% CI 2.62–3.65) and stroke (OR 2.29, 95% CI 1.99–2.63). Gestational hypertension was associated with increased odds of heart failure (OR 1.35, 95% CI 1.14–1.60) but not with most other cardiovascular outcomes. Conclusions Long-term cardiovascular risk following HDP varies by subtype, with all major subtypes demonstrating increased risk compared with normotensive pregnancies and larger effect estimates observed among women with superimposed preeclampsia. These findings support consideration of hypertensive disorder subtype in postpartum cardiovascular risk assessment.