Our results suggest that internists and ob-gyns have limited knowledge of the increased cardiovascular risks for women following preeclampsia. Up to 8% of parous women have a history of preeclampsia and therefore an increased risk for CVD. However, our study shows that few providers include preeclampsia in the medical history and even fewer counsel women with a history of preeclampsia regarding the increased risk of future CVD. While preeclampsia may provide an early window15
into a woman’s long-term risk of CVD, only a minority of providers recognize this opportunity for primary prevention and appropriately counsel these high-risk women.
Although most physicians were aware of an association between preeclampsia and future hypertension, these same physicians did not apply this knowledge to patient counseling as only 9% of internists and 38% of ob-gyns counseled women with a history of preeclampsia regarding their increased CVD risk. Nearly all internists and ob-gyns in our study provide preventative counseling on Pap test surveillance, and the majority reported providing CVD risk reduction counseling. However, our data indicate that physicians who routinely counsel for primary prevention of CVD are not well informed about the increased risk conferred by a history of preeclampsia. Thus, this increased risk is not assessed and the high-risk women with prior preeclampsia are not routinely counseled about their elevated risk of CVD.
While the precise pathophysiology of preeclampsia is not understood, large cohort studies2–5, 13
confirm the strong association with future CVD, stroke and renal disease, and there is evidence supporting a plausible biologic mechanism. The systemic endothelial damage caused by preeclampsia may indicate an underlying vascular condition that increases the risk for CVD or perhaps an unknown genetic predisposition for CVD first presenting during a woman’s pregnancy.
A history of preeclampsia identifies a group of women at higher risk of developing CVD. Although additional research is needed to determine whether specific cardio-protective interventions for women with a history of preeclampsia decrease morbidity, risk reduction counseling and close monitoring of modifiable risk factors such as cholesterol, hypertension and weight may reduce this group of women’s CVD risk. However, this risk reduction counseling can only occur if providers are aware of both the association and their patients’ obstetrical history.
Our results are similar to prior studies evaluating primary care providers’ knowledge of CVD prevention for women. A large study found that ob-gyns, internists and cardiologists assigned women to a lower-risk category than men with identical risk profiles.16
In this study, fewer than half of the providers counseled their patients about basic primary preventative measures to prevent CVD such as diet, exercise and weight loss. A minority of physicians knew that more women than men died of CVD annually.16
A study analyzing preventive services used by female patients found only 23% of women received counseling on diet and exercise.14
These studies, coupled with our findings, suggest that knowledge among primary care providers for primary prevention of CVD in women is limited.
In the United States, CVD remains the leading cause of death among women.11
There were 325 million primary care visits for women in this country in 200617
with each visit offering an opportunity for cardiovascular protection counseling. Successful adoption of practice guidelines has been correlated to physician awareness.16
The majority of internists and ob-gyns in this study were unaware of the positive correlation between preeclampsia and future CVD, cerebrovascular disease and renal disease, indicating that primary care providers may need more education about this association. The development of national guidelines may help physicians better identify and counsel this group of high-risk women.
Our study has a few limitations. One limitation is its potentially limited external validity given the large proportion of respondents who were residents. Though residents in a tertiary care center may have more didactic training and more exposure to recent clinical updates than the average primary care provider. Therefore, the percentage of providers knowledgeable about the association between preeclampsia and future CVD may be elevated compared to providers outside of an academic medical center. Ob-gyns demonstrated better knowledge of disease risks following preeclampsia and were more likely to obtain an obstetrical history that included preeclampsia. These findings may be secondary to more preeclampsia-related research and provider education in the department. In addition, respondents’ answers may have been influenced by how they suspected the authors wanted them to answer. Although we attempted to create questions that did not suggest a particular answer and asked about diseases unrelated to preeclampsia, we cannot eliminate this possibility. If this did occur, the level of knowledge demonstrated in our study may be artificially high.
In conclusion, this survey of internists and ob-gyns at an academic medical center indicates that knowledge about the association between preeclampsia and future CVD for women is deficient, thereby limiting the application of this risk factor to clinical care. Development of guidelines to assist providers in identifying and counseling women with a history of preeclampsia may help reduce CVD morbidity.