1. Women with heart disease had were at greater risk of cardiovascular events postpregnancy, compared to women without heart disease.
2. Tools that assess cardiovascular risk in pregnant women were able to identify higher risk individuals who later experienced adverse cardiovascular events.
Evidence Rating Level: 2 (Good)
The number of women with heart disease undergoing pregnancy is growing, which is currently at 1-4% of pregnancies. Having heart disease in pregnancy is associated with greater risk of cardiac and pregnancy complications, due to the increased hemodynamic stress. However, the long-term cardiac outcomes postpregnancy for this population has not been systematically studied. This retrospective cohort study based in Ontario, Canada compared the long-term cardiovascular outcomes of pregnancy between women with and without heart disease, and also examined the utility of pregnancy risk prediction tools to identify women at risk of adverse cardiac outcomes. The study population consisted of 1014 women with heart disease that had given birth between 1994 and 2015, each matched to two women without heart disease, but with a similar cardiovascular risk score based on demographics. The primary outcomes were all-cause mortality, myocardial infarction, stroke, heart failure, arrhythmia, or atrial fibrillation. Secondary outcomes included cardiovascular death, cardiac procedures, diabetes, or hypertension. The results found that there were 25.3 events per 1000-person years in the heart disease group, compared to 1.1 events in the group without heart disease. This translated to a hazards ratio of 19.6 (95% CI 13.8-29.0, p < 0.0001). The incidence of a primary outcome was 20.1% at 10 years and 33.1% at 20 years in the heart disease group, compared to 2.1% in the control group. There was also a higher rate of secondary outcomes at 20 years, such as cardiovascular death (1.0 versus 0.04 per 1000 person-years), cardiac procedures (30.6% versus 0.5%), and hypertension or diabetes mellitus (27.2% versus 18.4%). Furthermore, tools that estimate cardiovascular risk for pregnant women (such as CARPREG and WHO) were useful in predicting the primary outcomes: For example, heart disease patients in WHO classes III and IV had an incidence of 52.8% and 54.2% respectively, compared to just 12.% for WHO class I patients. Overall, the study demonstrated that pregnant women with heart disease are at elevated risk for cardiovascular events in the long-term, demonstrating the need for risk assessment and continued surveillance of this population postpregnancy.
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