Abstract Body: Hypertensive disorders of pregnancy (HDP) are related to poor cardiovascular sequelae, but the onset and mechanisms are unclear. Using real-world clinical data, we compared mid-life exercise stress echocardiogram variables between postpartum individuals with versus without HDP.

This retrospective chart review linked records of women with singleton pregnancies delivered from 1988-2023 to exercise stress echocardiography occurring >40 days (median [IQR] 8.2 [4.2-14.4] years) following delivery, excluding those with pre-pregnancy hypertension. We tested associations of HDP with peak exercise systolic and diastolic blood pressure (BP), exercise duration, and resting echocardiography parameters of diastolic dysfunction and left ventricular (LV) hypertrophy using linear regression. All models were adjusted for maternal age and time elapsed between delivery and the exercise test. Models of peak exercise BP were also adjusted for resting BP and exercise duration.

In the full cohort (no HDP n=845, HDP n=47, mean ± SD 30.7 ± 5.6 years at delivery), HDP was associated with shorter exercise duration, greater LV septal and posterior wall thickness, and worse diastolic function parameters including lower E’ velocity and higher E/E’ ratio (Table). Those with HDP were five years younger at the time of exercise testing than those without HDP (36.6 ± 6.0 vs. 41.6 ± 7.4 years). Thus, we repeated analyses restricting the time interval to within five years of delivery. In this subset (no HDP n=234, HDP n=25), peak systolic BP was 10.7 ± 4.3 mmHg higher in those with HDP. Between-group differences in exercise time and resting echocardiography parameters were similar in the subsample to findings in the full cohort.

Our results suggest that among women free of pre-pregnancy hypertension who are later referred for clinical exercise stress testing, those with prior HDP presented for exercise stress testing five years earlier. They also had lower exercise tolerance and higher systolic BP at peak exercise than women with normotensive pregnancy, even when adjusted for resting BP. Combined with worse echocardiographic parameters of diastolic dysfunction and LV hypertrophy, this suggests an accelerated timeline of structural and functional decline in women with HDP. These findings highlight the importance of postpartum cardiovascular surveillance and early interventions in this symptomatic patient population and could inform future screening strategies in women recovering from HDP.