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AHA Statements Detail Perinatal Heart Failure and Stroke Risks, Management, and Disparities

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Cardiovascular Risks in Pregnancy: New Guidance on Heart Failure and Stroke

Heart disease is a leading cause of pregnancy-related death in the U.S., with nearly one in four women aged 20-44 living with some form of cardiovascular disease.

The American Heart Association (AHA) has released two new scientific statements addressing cardiovascular complications during pregnancy and the postpartum period. One statement focuses on heart failure, detailing risk factors, diagnostic challenges, and management strategies. A second statement, endorsed by the American College of Obstetricians & Gynecologists (ACOG), addresses stroke risks, prevention, and treatment. A separate preliminary study has further identified an elevated risk of recurrent stroke in pregnant women with a prior stroke history.

Heart Failure During Pregnancy and Postpartum

Prevalence and Risk

According to the AHA statement on perinatal heart failure, heart disease is a leading cause of pregnancy-related death in the U.S. The statement notes that nearly one in four women aged 20-44 have some type of cardiovascular disease. Heart failure contributes to a significant proportion of pregnancy-related deaths, including 14.5% among American Indian/Alaska Native women and 14.2% among Black women.

Risk Factors for Perinatal Heart Failure

The statement identifies both general and perinatal-specific risk factors:

  • General risk factors: High blood pressure, Type 2 diabetes, abnormal cholesterol, overweight/obesity, and metabolic syndrome.
  • Perinatal risk factors: Pre-existing heart disease, older maternal age, multiple gestation, genetic variants, assisted reproductive technology, and prolonged use of tocolytic agents.

Disparities in Diagnosis and Outcomes

The AHA statement reports significant disparities in heart failure diagnosis and outcomes:

Black adults have approximately a 19% higher risk of developing heart failure than white adults.

  • Black and Native American women are diagnosed with peripartum cardiomyopathy (PPCM) more frequently than white women.
  • Black women with PPCM are more likely to be diagnosed at a later stage.

Consequences of Delayed Diagnosis

Pregnant women with heart failure are about 32 times more likely to die around delivery. Other reported risks include irregular heartbeat, stroke, worsening cardiac function, preterm delivery, C-section, postpartum hemorrhage, poor mental health, restricted fetal growth, premature birth, low birth weight, stillbirth, and infant death.

Diagnosis, Management, and Postpartum Care

  • Diagnosis: Evaluation includes ECG, blood tests for cardiac biomarkers, and echocardiograms.
  • Treatment: Involves medications considered safe in pregnancy (beta blockers, diuretics, vasodilators, anticoagulants) and management by a multidisciplinary cardio-obstetrics team.
  • Lifelong health: Emphasis is placed on maintaining Life's Essential 8 cardiovascular health metrics.
  • Postpartum monitoring: The statement recommends monitoring through the first year after delivery, including home visits, telemedicine, and remote monitoring.
  • Contraception: Long-acting reversible contraceptives (e.g., hormonal IUDs) are preferred; estrogen-containing methods are not recommended for women with moderate or severe heart failure.

Stroke During Pregnancy and Postpartum

Incidence and Research Background

The AHA stroke statement reports that stroke occurs in approximately 20 to 40 out of every 100,000 pregnancies and accounts for an estimated 4-6% of annual pregnancy-related deaths in the U.S. Strokes are classified as ischemic (blood vessel blockage) or hemorrhagic (blood vessel rupture). The statement notes that historically, pregnant and postpartum women have been excluded from clinical trials, but observational research over the past decade has informed care.

Risk Factors for Maternal Stroke

Identified risk factors include:

  • Chronic hypertension (high blood pressure before or by 20 weeks of pregnancy)
  • Hypertensive disorders of pregnancy (e.g., gestational hypertension, preeclampsia/eclampsia)
  • Advanced maternal age (35 years or older)
  • Diabetes
  • Obesity
  • Migraine, particularly with aura
  • Infections
  • Heart or cerebrovascular disease
  • Clotting disorders

A 2020 meta-analysis found that Black pregnant women are twice as likely to experience a stroke compared to white pregnant women, even when adjusting for socioeconomic factors.

Prevention Strategies

The statement emphasizes that stroke prevention ideally begins before conception. Recommendations include:

  • Adopting primary stroke prevention strategies and healthy lifestyle behaviors (smoking cessation, healthy eating, physical activity, weight management).
  • Early and aggressive blood pressure control, using ACOG's diagnostic criteria (systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg).
  • Close monitoring of blood pressure, especially in the early postpartum period.
  • Use of antihypertensive medications during pregnancy and postpartum.
  • Daily low-dose aspirin to reduce preeclampsia risk in high-risk individuals.

Diagnosis and Treatment

  • Recognition: Healthcare professionals involved in the care of pregnant patients should be trained to recognize stroke symptoms for prompt treatment.
  • Imaging: Computed tomography (CT), CT angiography, and magnetic resonance imaging (MRI) without contrast are considered safe for rapid evaluation in pregnant patients with acute stroke symptoms.
  • Treatment: The statement states pregnancy should not delay recommended acute stroke treatment. Anti-clotting medications safe for pregnant and lactating women are available. Mechanical thrombectomy may be necessary for patients with large-vessel blockages.

Delivery and Recovery

  • Delivery: Stroke during pregnancy does not automatically necessitate immediate delivery if the mother's condition is stable and the fetus is preterm. If the mother's neurological or cardiovascular status deteriorates, preterm delivery may be required. Cesarean delivery is preferably avoided to minimize surgical risks and blood pressure changes.
  • Recovery: Survivors of pregnancy-associated stroke may face challenges in infant care and require support from a multidisciplinary rehabilitation team. Mood and sleep disorders, post-stroke fatigue, anxiety, and depression are common and may be intensified by postpartum factors. Management includes behavioral therapy, counseling, and medication. Involving family members and caregivers in rehabilitation planning is recommended.

Preliminary Study: Recurrent Stroke Risk

Key Findings

A preliminary study presented at the American Stroke Association's International Stroke Conference 2026 analyzed electronic health records from 2015 to 2025, including 220,479 pregnant women aged 15 to 50. The study found:

Women with a history of prior ischemic stroke were more than twice as likely to have a recurrent stroke during pregnancy and the early postpartum period.

  • The risk of ischemic stroke during pregnancy and early postpartum was 82% higher for pregnant women with a previous heart attack.
  • The risk was 25% higher for pregnant women with obesity.

Study Data

Among the studied population:

  • The stroke rate among women with a previous stroke was 34.82% (415 new ischemic strokes among 1,192 pregnant women).
  • The stroke rate among women without a prior stroke was 0.34% (737 new strokes among 219,287 women).

Expert Recommendations

Dr. Adnan I. Qureshi, the study's lead author, stated that the increased risk for women with a prior stroke is not influenced by other risk factors and suggested these pregnancies be managed at specialized healthcare centers, noting the current absence of specific clinical guidelines for this demographic. Dr. Jennifer Lewey highlighted the importance of pre-conception counseling for women with a history of ischemic stroke and suggested interdisciplinary teams of neurologists and obstetricians could develop comprehensive surveillance and treatment plans.

Study Limitations

The study is an observational analysis reliant on a large database of electronic health records. The findings are considered preliminary, as abstracts presented at AHA/American Stroke Association scientific meetings have not been peer-reviewed and await publication as full manuscripts in a peer-reviewed scientific journal.