The risk of atrial fibrillation (AF) is increased by all adverse pregnancy outcomes except small for gestational age, according to a recent study published in JAMA Cardiology.1
AF has been indicated as a growing public health burden, impacting more than 50 million patients worldwide. Reproductive-aged women are especially experiencing a growing prevalence. Additionally, adverse pregnancy outcomes have been reported as factors influencing future cardiovascular health.
Key takeaways:
- A Swedish national cohort study found that 5 of 6 major adverse pregnancy outcomes were linked to a higher risk of atrial fibrillation (AF) later in life.
- The strongest associations with AF were observed for other hypertensive disorders of pregnancy, preeclampsia, and preterm delivery.
- Risks for AF often persisted for decades, with some appearing up to 20 years after delivery.
- Small for gestational age was the only adverse pregnancy outcome not associated with increased AF risk.
- Experts emphasize the need for early cardiovascular prevention and long-term follow-up for women with adverse pregnancy outcomes.
“Most studies have had insufficient follow-up times (<15 years) to assess risk at older ages when AF is more common,” wrote investigators.
Assessing AF risk
The national cohort study was conducted to address these knowledge gaps and assess AF risk in patients with major adverse pregnancy outcomes. Data about women with singleton delivery from 1973 to 2015 was obtained from the Swedish Medical Birth Register. Women with a prior AF diagnosis were excluded from the analysis.
Preterm delivery, small for gestational age (SGA), large for gestational age (LGA), preeclampsia, other hypertensive disorders of pregnancy, and gestational diabetes were reported as major adverse pregnancy outcomes. SGA was defined as birth weight under the 10th percentile for gestational age, and LGA as above the 90th percentile.
Follow-up lasted through December 31, 2018, with a maximum duration of 46 years and a median duration of 25 years. International Classification of Diseases codes were used to diagnose AF. Covariates included maternal age, parity, calendar year of delivery, employment status, income, and education level.
AF risk by pregnancy outcome
There were 2,201,047 women included in the final analysis, 39.3% of whom experienced at least 1 major adverse pregnancy outcome. LGA, SGA, and preterm delivery were the most common outcomes, reported in 14.8%, 14.3%, and 8.9%, respectively. AF was reported in 2.3% of participants across 54 million person-years of follow-up.
Participants were aged a median of 27 years at first delivery, 63 years at AF diagnosis, and 53 years at the end of follow-up. An association was reported with AF for all major adverse pregnancy outcomes except SGA.
Other hypertensive disorders of pregnancy had the greatest link to AF, with a hazard ratio of 1.46. This was followed by:
- Preeclampsia (HR, 1.36)
- LGA (HR, 1.19)
- Preterm delivery (HR, 1.14)
- Gestational diabetes HR, 1.12)
- SGA (HR, 0.98)
Time-sensitive AF risks
HRs for AF remained significantly elevated only in women with other hypertensive disorders, preterm delivery, and LGA when evaluated within 10 years following delivery, at 1.69, 1.46, and 1.16, respectively. At 30 to 46 years after delivery, these HRs were 1.44, 1.11, and 1.17, respectively.
Additionally, increases in HRs of AF for preeclampsia and gestational diabetes were reported during this period, at 1.38 and 1.19, respectively. The greatest percent of AF cases of 5.1% was reported in preeclampsia patients, vs 3.1% for LGA and under 2% for other adverse pregnancy outcomes.
Overall, the data indicated associations with AF for 5 of the 6 major adverse pregnancy outcomes. Investigators noted some risks appeared 20 years after delivery and were significantly mediated by other incident cardiovascular conditions post-pregnancy.
“Women with adverse pregnancy outcomes need early preventive actions and long-term follow-up for timely detection and treatment of cardiovascular disorders related to the development of AF,” wrote investigators.
Expert commentary on preventive care
Methods to address health disparities and manage adverse pregnancy outcomes for improved health were highlighted by Angela Bianco, MD, a maternal-fetal medicine expert and director at Mount Sinai Health System, in an interview with Contemporary OB/GYN. During the discussion, cardiovascular disease was highlighted as a leading cause of maternal mortality.2
According to Bianco, a multi-pronged approach is needed to address these challenges. This includes diversifying the health care workforce and implementing a doula program to provide continuous, culturally competent support during the antepartum and postpartum periods.
“If we work together as a team and recognize our shortcomings, we can actually make a significant difference and chip away at the… differences in our maternal mortality and morbidity rates,” said Bianco.
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