Impact of a History of Hypertension in Pregnancy on Later Diagnosis of Atrial Fibrillation

Left Atrial Mechanics Following Preeclamptic Pregnancy

BACKGROUND

Preterm preeclampsia is a pregnancy complication associated with myocardial dysfunction and premature cardiovascular disease morbidity and mortality. Left atrial (LA) strain is a noninvasive index of left ventricular end diastolic pressure and an early marker of heart failure risk. This study aimed to evaluate LA strain during the postpartum period in participants with and without preterm preeclampsia and to assess whether this varied in the presence of hypertension, cardiac dysfunction or both.

METHODS

In this longitudinal cohort study, 321 women from 28 hospitals with preterm preeclampsia (cases) underwent cardiovascular assessment 6 months postpartum. This is a secondary analysis of the PHOEBE study (ISRCTN01879376). An uncomplicated pregnancy control group (n=30) was recruited from a single center for comparison. A full cross-sectional transthoracic echocardiogram was performed, and from these images, the myocardial strain of the left atrium, including reservoir, conduit, and contractile strain, as well as LA stiffness, were calculated.

RESULTS

At 6 months postpartum, compared with controls, prior preeclampsia was associated with a significantly attenuated LA reservoir, conduit, and contractile strain, as well as increased LA stiffness (all P<0.001). LA strain was further reduced in preeclamptic women who had and had not developed hypertension, systolic, or diastolic dysfunction at 6 months postpartum (all P<0.05).

CONCLUSIONS

LA mechanics were significantly attenuated at 6 months postpartum in participants with preterm preeclampsia, whether or not they remained hypertensive or had evidence of ventricular dysfunction. Further studies are needed to determine whether postnatal LA strain may identify women at greater risk for future cardiovascular disease.

The Role of Helicobacter pylori and Metabolic Syndrome-Related Mast Cell Activation Pathologies and Their Potential Impact on Pregnancy and Neonatal Outcomes

Helicobacter pylori infection, a significant global burden beyond the gastrointestinal tract, has long been implicated in various systemic pathologies. Rising evidence suggests that the bacterium's intricate relationship with the immune system and its potential to induce chronic inflammation impact diverse pathophysiological processes in pregnant women that may in turn affect the incidence of several adverse pregnancy and neonate outcomes. Helicobacter pylori infection, which has been linked to metabolic syndrome and other disorders by provoking pericyte dysfunction, hyperhomocysteinemia, galectin-3, atrial fibrillation, gut dysbiosis, and mast cell activation pathologies, may also contribute to adverse pregnancy and neonatal outcomes. Together with increasing our biological understanding of the individual and collective involvement of Helicobacter pylori infection-related metabolic syndrome and concurrent activation of mast cells in maternal, fetus, and neonatal health outcomes, the present narrative review may foster related research endeavors to offer novel therapeutic approaches and informed clinical practice interventions to mitigate relevant risks of this critical topic among pregnant women and their offspring.

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation.

METHODS

A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate.

STRUCTURE

Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.

The Challenge of Managing Atrial Fibrillation during Pregnancy

The incidence of atrial fibrillation (AF) during pregnancy increases with maternal age and with the presence of structural heart disorders. Early diagnosis and prompt therapy can considerably reduce the risk of thromboembolism. The therapeutic approach to AF during pregnancy is particularly challenging, and the maternal and fetal risks associated with the use of antiarrhythmic and anticoagulant drugs must be carefully evaluated. Moreover, the currently used thromboembolic risk scores have yet to be validated for the prediction of stroke during pregnancy. At present, electrical cardioversion is considered to be the safest and most effective strategy in women with hemodynamic instability. Beta-selective blockers are also recommended as the first choice for rate control. Antiarrhythmic drugs such as flecainide, propafenone and sotalol should be considered for rhythm control if atrioventricular nodal-blocking drugs fail. AF catheter ablation is currently not recommended during pregnancy. Overall, the therapeutic strategy for AF in pregnancy must be carefully assessed and should take into consideration the advantages and drawbacks of each aspect. A multidisciplinary approach with a "Pregnancy-Heart Team" appears to improve the management and outcome of these patients. However, further studies are needed to identify the most appropriate therapeutic strategies for AF in pregnancy.

Cardiovascular Disease-Related Emergency Department Visits and Hospitalization among Women with Hypertensive Disorders of Pregnancy

INTRODUCTION

The risk of developing cardiovascular disease is higher for women who had hypertensive disorders of pregnancy than for women without a history of hypertensive disorders of pregnancy. However, it is unknown whether the emergency department visits and hospitalization differ between women with a history of hypertensive disorders of pregnancy and women without hypertensive disorders of pregnancy. The objective of this study was to characterize and compare cardiovascular disease-related emergency department visits, hospitalization rates, and diagnoses in women with a history of hypertensive disorders of pregnancy with those in women without.

METHODS

This study included participants from the California Teachers Study (N=58,718) with a history of pregnancy and data from 1995 through 2020. Incidence of cardiovascular disease-related emergency department visits and hospitalizations based on linkages with hospital records were modeled using multivariable negative binomial regression. Data were analyzed in 2022.

RESULTS

A total of 5% of the women had a history of hypertensive disorders of pregnancy (5.4%, 95% CI=5.2%, 5.6). A total of 31% of women had 1 or more cardiovascular disease-related emergency department visits (30.9%), and 30.1% had 1 or more hospitalizations. The incidence of cardiovascular disease-related emergency department visits (adjusted incident rate ratio=8.96, p<0.001) and hospitalizations (adjusted incident rate ratio=8.88, p<0.001) were significantly higher for women with hypertensive disorders of pregnancy than for those without, adjusting for other related characteristics of the women.

CONCLUSIONS

History of hypertensive disorders of pregnancy is associated with higher cardiovascular disease-related emergency department visits and hospitalizations. These findings underscore the potential burden on women and the healthcare system of managing complications associated with hypertensive disorders of pregnancy. Evaluating and managing cardiovascular disease risk factors in women with a history of hypertensive disorders of pregnancy is necessary to avoid cardiovascular disease-related emergency department visits and hospitalizations in this group.

Pregnancy-Related Complications and Incidence of Atrial Fibrillation: A Systematic Review

Pregnancy-related complications are associated with a higher risk of various incident cardiovascular diseases, but their specific potential relationship with incident atrial fibrillation (AF) is less clear. This systematic review summarises the available evidence from observational studies which have examined associations between pregnancy-related complications and the risk of AF. MEDLINE and EMBASE (Ovid) were searched for studies between 1990 to 10 February 2022. Pregnancy-related complications examined included hypertensive disorders of pregnancy (HDP), gestational diabetes, placental abruption, preterm birth, small-for-gestational-age and stillbirth. Study selection, data extraction and quality assessment were completed independently by two reviewers. Narrative synthesis was used to evaluate the results of the included studies. Nine observational studies were included, with eight eligible for narrative synthesis. Sample sizes ranged from 1839 to 2,359,386. Median follow-up ranged from 2 to 36 years. Six studies reported that pregnancy-related complications were associated with a significantly increased risk of incident AF. Hazard ratios (HRs) (95% confidence intervals) for the four studies that evaluated HDP ranged from 1.1 (0.8-1.6) to 1.9 (1.4-2.7). For the four studies that evaluated pre-eclampsia, HRs ranged from 1.2 (0.9-1.6) to 1.9 (1.7-2.2). Current evidence from observational studies suggests pregnancy-related complications are associated with a significantly higher risk of incident AF. However, only a small number of studies examining each pregnancy-related complication were identified, and considerable statistical heterogeneity was observed. Further large-scale prospective studies are required to confirm the association between pregnancy-related complications and incident AF.

Cardiac electrical and structural alterations in preeclampsia

BACKGROUND

Preeclampsia increases the risk of cardiovascular mortality and morbidity both during pregnancy and long term after the labor by causing cardiac changes that may lead to atrial and ventricular arrhythmias.

OBJECTIVE

We aimed to investigate noninvasive predictors of atrial and ventricular arrhythmias and cardiac structural changes in preeclampsia.

METHODS

The study included 34 preeclampsia patients as the study group and 33 healthy pregnant women as the control group. The presence of fragmented QRS morphology, P dispersion, QT dispersion, Tp-e/QTc ratio, inter- and intra-atrial electromechanical delay, left ventricular mass index was evaluated in the groups by 12 lead- ECG and standard and tissue Doppler echocardiography.

RESULTS

Left ventricular mass index and relative wall thickness, and E/Em ratio was significantly higher in preeclampsia. Inter- and intra-atrial electromechanical delay and Tp-e were prolonged, and P dispersion, QT dispersion, and Tp-e/QTc ratio were increased significantly in patients with preeclampsia. In addition, fragmented QRS morphology was seen in 76.5% of patients with preeclampsia while it was present in only 27.3% of the control group (p < .001).

CONCLUSION

Preeclampsia causes significant cardiac structural and electrocardiographic alterations that may increase the risk of atrial and/or ventricular arrhythmias. A more thorough and earlier cardiac assessment and closer follow-up of these patients would be useful to avoid further complications.

Gestational systolic blood pressure trajectories and risk of adverse maternal and perinatal outcomes in Chinese women

Background

Associations between trajectories of systolic blood pressure (SBP) during pregnancy and pregnant outcomes remain unclear and disparate.

Methods

Data of 20,353 mothers without chronic hypertension and who delivered live singletons between January, 2014 and November, 2019, was extracted from Taicang register-based cohort. Based on SBP measured during 10 to 40 weeks of gestation, SBP trajectories were explored using latent class growth mixture model, and their associations with maternal and neonatal outcomes were assessed by logistic regression analyses.

Results

Six heterogeneous SBP trajectories were identified: low delayed-increasing (7.47%), low reverse-increasing (21.88%), low-stable (19.13%), medium-stable (21.64%), medium reverse-increasing (16.47%), and high stable (13.41%) trajectories. The high-stable trajectory had SBP around 125 mmHg in the 10th gestational week, and increased slightly onwards. When compared with the low-stable trajectory, the high-stable trajectory had maximally adjusted odds ratio (95% confidence interval) of 5.28 (2.76–10.10), 1.30 (1.13–1.50), 1.53 (1.12–2.08), 1.32 (1.06–1.65) and 1.64 (1.08–2.48) for gestational hypertension (GH), early-term delivery (ETD), preterm delivery (PTD), small for gestational age and low birth weight (LBW), respectively. Besides, the medium reverse-increasing trajectory showed significantly increased risk of GH and ETD, while the medium-stable trajectory had significantly elevated risk of ETD and PTD. Notably, SBP trajectories slightly but significantly improved risk discrimination of GH, ETD and LBW, over traditional risk factors.

Conclusion

Women with different SBP trajectories were at varied risk of adverse maternal and fetal outcomes. Meanwhile, our study suggested that BP monitoring during pregnancy is necessary, especially for women with high SBP in early pregnancy or upward trajectory.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03599-7.

Differences in Epidemiology and Risk Factors for Atrial Fibrillation Between Women and Men

Atrial fibrillation (AF), the most common sustained cardiac arrhythmia, is one of the most frequent cardiovascular diseases among both women and men. Although age-adjusted AF incidence and prevalence is larger among men, women are older at the time of AF diagnosis and have larger risk for AF-associated adverse outcomes such as morality and stroke. Based on evidence from epidemiological studies, elevated body mass index seems to confer a higher risk of AF among men. However, evidence regarding sex differences in the association between diabetes mellitus, elevated blood pressure, and dysglycemia with AF remains conflicting. While men with AF have larger burden of coronary artery disease, women with AF tend to have a larger prevalence of heart failure and valvular heart disease. Recently, several women-specific risk factors including pregnancy and its complications and number of children have been associated with AF. Earlier age at menopause, despite being a strong marker of adverse cardiometabolic risk, does not seem to be associated with increased risk of AF. To reduce the AF burden in both genders, better understanding of the differences between women and men with regard to AF is central. Large-scale studies are needed to separately investigate and report on women and men. Besides observations from epidemiological and clinical studies, to improve our understanding of sexual dimorphism in AF, sufficiently large genome-wide association studies as well as well-powered Mendelian randomization studies are essential to shed light on the sex-specific nature of the associations of risk factors with AF.

Long-Term Cardiovascular Risk in Women With Hypertension During Pregnancy

BACKGROUND

History of a hypertensive disorder of pregnancy (HDP) among women may be useful to refine atherosclerotic cardiovascular disease risk assessments. However, future risk of diverse cardiovascular conditions in asymptomatic middle-aged women with prior HDP remains unknown.

OBJECTIVES

The purpose of this study was to examine the long-term incidence of diverse cardiovascular conditions among middle-aged women with and without prior HDP.

METHODS

Women in the prospective, observational UK Biobank age 40 to 69 years who reported ≥1 live birth were included. Noninvasive arterial stiffness measurement was performed in a subset of women. Cox models were fitted to associate HDP with incident cardiovascular diseases. Causal mediation analyses estimated the contribution of conventional risk factors to observed associations.

RESULTS

Of 220,024 women included, 2,808 (1.3%) had prior HDP. The mean age at baseline was 57.4 ± 7.8 years, and women were followed for median 7 years (interquartile range: 6.3 to 7.7 years). Women with HDP had elevated arterial stiffness indexes and greater prevalence of chronic hypertension compared with women without HDP. Overall, 7.0 versus 5.3 age-adjusted incident cardiovascular conditions occurred per 1,000 women-years for women with versus without prior HDP, respectively (p = 0.001). In analysis of time-to-first incident cardiovascular diagnosis, prior HDP was associated with a hazard ratio (HR) of 1.3 (95% CI: 1.04 to 1.60; p = 0.02). HDP was associated with greater incidence of CAD (HR: 1.8; 95% CI: 1.3 to 2.6; p < 0.001), heart failure (HR: 1.7; 95% CI: 1.04 to 2.60; p = 0.03), aortic stenosis (HR: 2.9; 95% CI: 1.5 to 5.4; p < 0.001), and mitral regurgitation (HR: 5.0; 95% CI: 1.5 to 17.1; p = 0.01). In causal mediation analyses, chronic hypertension explained 64% of HDP's association with CAD and 49% of HDP's association with heart failure.

CONCLUSIONS

Hypertensive disorders of pregnancy are associated with accelerated cardiovascular aging and more diverse cardiovascular conditions than previously appreciated, including valvular heart disease. Cardiovascular risk after HDP is largely but incompletely mediated by development of chronic hypertension.

Incidence of atrial fibrillation in pregnancy and clinical significance: A meta-analysis

PURPOSE

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia worldwide, and is associated with increased morbidity and mortality. However, the incidence and maternal/fetal outcomes of AF in pregnancy remain unclear. This study's aims were to investigate the pooled incidence of AF in pregnant women and to assess maternal/fetal outcomes of AF in pregnancy.

MATERIAL AND METHODS

A literature search for studies that reported incidence of AF in pregnancy, was conducted using MEDLINE, EMBASE and Cochrane Database from inception through May 2018. Pooled incidence with 95%CI were calculated using a random-effect model. The protocol for this meta-analysis is registered with PROSPERO (International Prospective Register of Systematic Reviews; no. CRD42018095955).

RESULTS

We identified 7 cohort studies including 301,638 pregnancies. The pooled estimated incidence of AF in pregnancy among women with no known heart disease, and those with structural heart disease was 0.3% (95%CI: 0.01%-40.6%) and 2.2% (95%CI: 0.96%-5.01%), respectively. Among women with known AF, the pooled estimated incidence of recurrent AF in pregnancy was 39.2% (95%CI: 16.9%-67.2%). The pooled estimated incidence of pre-eclampsia and congestive heart failure among pregnant patients with AF was 4.1% (95%CI: 2.1%-7.8%) and 9.6% (95%CI: 5.7%-15.9%), respectively. The pooled estimated incidence of fetal events including premature birth, small for gestational age, respiratory distress syndrome, intraventricular hemorrhage, death was 26.6% (95%CI: 20.4%-34.0%).

CONCLUSION

The overall estimated incidence of AF and recurrent AF during pregnancy is as high as 2.2% and 39.2%, respectively. AF during pregnancy may result in poor maternal and fetal outcomes.

Gender Differences in Atrial Fibrillation: A Review of Epidemiology, Management, and Outcomes

Atrial fibrillation is the most common sustained cardiac arrhythmia. The scope and impact of atrial fibrillation are wide; it can affect cardiac function, functional status, and quality of life, and it confers a stroke risk. There are sex differences in atrial fibrillation across the scope of the disease process, from epidemiology and causative mechanisms to management and outcomes. The approach to management of atrial fibrillation differs between women and men, and there are sex differences in response to medical therapy and catheter ablation. There are many gaps in our knowledge of the gender differences in atrial fibrillation, and many opportunities for future research.