Cardiac Remodeling After Hypertensive Pregnancy Following Physician-Optimized Blood Pressure Self-Management: The POP-HT Randomized Clinical Trial Imaging Substudy.

Background: Hypertensive pregnancy disorders are associated with adverse cardiac remodeling, which can fail to reverse in the postpartum period in some women. The Physician-Optimized Postpartum Hypertension Treatment trial demonstrated that improved blood pressure control while the cardiovascular system recovers postpartum associates with persistently reduced blood pressure. We now report the effect on cardiac remodeling.
Methods: In this prospective, randomized, open-label, blinded end point trial, in a single UK hospital, 220 women were randomly assigned 1:1 to self-monitoring with research physician-optimized antihypertensive titration or usual postnatal care from a primary care physician and midwife. Participants were 18 years of age or older, with preeclampsia or gestational hypertension, requiring antihypertensives on hospital discharge postnatally. Prespecified secondary cardiac imaging outcomes were recorded by echocardiography around delivery, and again at blood pressure primary outcome assessment, around 9 months postpartum, when cardiovascular magnetic resonance was also performed.
Results: A total of 187 women (101 intervention; 86 usual care) underwent echocardiography at baseline and follow-up, at a mean 258±14.6 days postpartum, of which 174 (93 intervention; 81 usual care) also had cardiovascular magnetic resonance at follow-up. Relative wall thickness by echocardiography was 0.06 (95% CI, 0.07-0.05; P <0.001) lower in the intervention group between baseline and follow-up, and cardiovascular magnetic resonance at follow-up demonstrated a lower left ventricular mass (-6.37 g/m ² ; 95% CI, -7.99 to -4.74; P <0.001), end-diastolic volume (-3.87 mL/m ² ; 95% CI, -6.77 to -0.98; P =0.009), and end-systolic volume (-3.25 mL/m ² ; 95% CI, 4.87 to -1.63; P <0.001) and higher left and right ventricular ejection fraction by 2.6% (95% CI, 1.3-3.9; P <0.001) and 2.8% (95% CI, 1.4-4.1; P <0.001), respectively. Echocardiography-assessed left ventricular diastolic function demonstrated a mean difference in average E/E' of 0.52 (95% CI, -0.97 to -0.07; P =0.024) and a reduction in left atrial volumes of -4.33 mL/m ² (95% CI, -5.52 to -3.21; P <0.001) between baseline and follow-up when adjusted for baseline differences in measures.
Conclusions: Short-term postnatal optimization of blood pressure control after hypertensive pregnancy, through self-monitoring and physician-guided antihypertensive titration, associates with long-term changes in cardiovascular structure and function, in a pattern associated with more favorable cardiovascular outcomes.
Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT04273854.
Competing Interests: Disclosures L.M. and P.L. are supported by the National Institute for Health and Care Research Oxford Biomedical Research Centre. L.M. is a part-time employee of EMIS Group plc. P.L. is a founder and shareholder of a health care imaging company and a named inventor on patents related to cardiovascular imaging. R.M. has received blood pressure monitors for research from Omron and has worked with Omron and Sensyne on telemonitoring interventions for which licensing and consultancy fees have been paid to the University of Oxford. C.R. has received consultancy fees from Sensyne Health for work on telemonitoring products. J.K. is an executive committee member of the British Society of Cardiac Imaging and Cardiac Computed Tomography. The other authors report no conflicts.