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. 2025 Jul 11;24(1):282.
doi: 10.1186/s12933-025-02811-8.

Maternal coronary heart disease and mortality following hypertensive disorders of pregnancy and/or diabetes

Angela M Malek  1 , Dulaney A Wilson  2 , Julio Mateus  3 , Emily A Ash  2 , Tanya N Turan  4 , Daniel T Lackland  4 , Kelly J Hunt  2
Affiliations

Maternal coronary heart disease and mortality following hypertensive disorders of pregnancy and/or diabetes

Angela M Malek et al. Cardiovasc Diabetol. .

Abstract

Background: Pre-pregnancy hypertension (HTN), hypertensive disorders of pregnancy (HDP), and diabetes have been linked to increased risk of post-pregnancy coronary heart disease (CHD) and all-cause mortality, but few studies have investigated their cumulative impact. This study aimed to assess the potential relationship between pre-pregnancy HTN, HDP, and diabetes and their cumulative impact on maternal cardiovascular outcomes defined as incident CHD and all-cause mortality within 5 years of delivery and over the entire study period (up to 14 years after delivery).

Methods: This retrospective cohort study included 430,545 women aged 12-49 with ≥ 1 singleton, live birth in South Carolina (2004-2016) including non-Hispanic White (NHW; 59.2%), non-Hispanic Black (NHB; 31.4%), and Hispanic (9.4%) women. Birth certificate and hospitalization/emergency department (ED) visit data defined pre-pregnancy HTN, HDP (preeclampsia, eclampsia, gestational HTN), and diabetes (pre-pregnancy, gestational). Hospitalization/ED visit and death certificate data defined incident CHD and all-cause mortality. Covariate-adjusted Cox proportional hazard models were used to assess associations between CHD and mortality by exposure.

Results: After adjustment for covariates relative to women without any of the three conditions (diabetes, pre-pregnancy HTN, HDP), incident CHD risk was increased within 5 years of delivery for women with diabetes (HR = 1.57; 95% CI 1.28-1.92), HDP (HR = 1.85; 95% CI 1.60-2.15), HDP and diabetes (HR = 2.29; 95% CI 1.73-3.03), HDP and pre-pregnancy HTN (HR = 3.13; 95% CI 2.66-3.68), and all three conditions (HR = 4.87; 95% CI 3.95-6.01). All-cause mortality risk was increased for diabetes (HR = 1.34; 95% CI 1.01-1.78), HDP and pre-pregnancy HTN (HR = 1.53; 95% CI 1.15-2.03), and all three conditions (HR = 2.25; 95% CI 1.51-3.36), but not HDP or HDP and diabetes.

Conclusions: Within 5 years of delivery, incident CHD and all-cause mortality rates were highest for women with two or three conditions, specifically HDP, diabetes, and/or pre-pregnancy HTN, with all rates higher for NHB than NHW women. Thus, it is critical to implement clinical prevention strategies to improve risk factor screening and identification among women of child-bearing age.

Keywords: Chronic hypertension; Coronary heart disease; Diabetes; Hypertensive disorders of pregnancy; Mortality.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: The Institutional Review Board (IRB) of the Medical University of South Carolina approved the study as expedited research (Pro00077152). Permission was received from the dataset owner to use the information in the databases for the purposes of this research. Patient consent was waived due to the use of previously existing data provided in a limited dataset, and as individuals will not be contacted or identified. Competing interests: The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
Study flow chart
Fig. 2
Fig. 2
Incident CHD events (per 1,000 person-years) among women ≤ 5 years following delivery and over the entire study period (≤ 14 years) by race/ethnicity and exposure group a. CHD, coronary heart disease; CI, confidence interval; HDP, hypertensive disorders of pregnancy; HR, hazard ratio; HTN, hypertension (pre-pregnancy); NHB, non-Hispanic Black; NHW, non-Hispanic White. a The total population included Hispanic women; however, the number of events were too low to present race/ethnic-specific events for Hispanic women
Fig. 3
Fig. 3
Maternal incident CHD survival within 5 years of delivery by populationa and exposure. CHD, coronary heart disease; HDP, hypertensive disorders of pregnancy; HTN, hypertension (pre-pregnancy). aTotal population includes Non-Hispanic White, Non-Hispanic Black, and Hispanic women. Hispanic-specific analysis was not run due to low counts
Fig. 4
Fig. 4
All-cause mortality events (per 1,000 person-years) among women ≤ 5 years following delivery and over the entire study period (≤ 14 years) by race/ethnicity and exposure group a. CI, confidence interval; HDP, hypertensive disorders of pregnancy; HR, hazard ratio; HTN, hypertension (pre-pregnancy); NHB, non-Hispanic Black; NHW, non-Hispanic White. a The total population included Hispanic women; however, the number of events were too low to present race/ethnic-specific events for Hispanic women
Fig. 5
Fig. 5
Maternal all-cause mortality within 5 years of delivery by populationa and exposure. HDP, hypertensive disorders of pregnancy; HTN, hypertension (pre-pregnancy). aTotal population includes Non-Hispanic White, Non-Hispanic Black, and Hispanic women. Hispanic-specific analysis was not run due to low counts
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