Hypertension During Pregnancy Linked With Subsequent A-fib in Women

Hypertensive pregnancy disorders, including gestational hypertension and preeclampsia, often lead to subsequent diagnoses of atrial fibrillation later in life, according to new data. As such, hypertension during pregnancy should be considered a risk factor for cardiovascular disease prevention that physicians should screen for and aggressively treat, according to the study author.

“This is . . . a public health issue,” lead author Dawn Scantlebury, MBBS (University of the West Indies, St. Michael, Barbados), told TCTMD. “It's something that physicians need to be aware of, and they need to start paying attention to women who have hypertension in pregnancy and just think of them as a high-risk patient. I think our outcomes would be better. I think the incidence of hypertension-related cardiovascular diseases would decrease if we were more aware and paid more attention to it.”

Pregnancy is basically a “stress test” to see how much a woman’s heart can handle, she explained. “During pregnancy, you have a high cardiac output, your preload goes up; if you have hypertension, your blood pressure goes up; [and] if you have metabolic syndrome or have other risk factors for preeclampsia, the hormonal changes can kind of unlash that.”

This is . . . a public health issue. Dawn Scantlebury

For their study, Scantlebury and colleagues identified 105 cases of A-fib from a database of more than 7,500 women who gave birth in Olmsted County, MN, between 1976 and 1982. Women with A-fib were more likely to be obese during childbearing years and have hypertension, diabetes, dyslipidemia, coronary disease, valvular disease, and heart failure at the time of A-fib diagnosis.

Compared with a control group of women without A-fib, those with the condition were more than twice as likely to have a history of hypertension during pregnancy (26.7% vs 11.4%; OR 2.60; 95% CI 1.21-6.04). This association was attenuated after adjustment for hypertension and obesity (OR 2.12; 95% CI 0.92-5.23).

The results were published online this week ahead of print in the Journal of the American Heart Association.

Follow-up Could ‘Nip This in the Bud’

“As I look at other studies that have come out, I realize that this is exactly what I was expecting,” Scantlebury said. “Atrial fibrillation is definitely more common in women who had a hypertensive pregnancy, and [while we] didn't demonstrate an independent association, [that] is not surprising either because they have more hypertension, they develop hypertension earlier, and they have more metabolic syndrome components that actually start even from before the pregnancy and during the pregnancy.”

She said she would like to see a prospective, longitudinal study performed of women with a history of hypertension in pregnancy that would potentially test the standard of care against a variety of interventions including ambulatory blood pressure monitoring at different intervals, treatment for those who need it, and subsequent 12-lead ECGs to track the development of A-fib. “Of course, it would be a long study,” Scantlebury acknowledged. “With these patients, they got A-fib 30 years after their first pregnancy. So we're looking at a very, very long study. But that would be the ideal.”

In a larger study, Scantlebury said she would expect to see a stronger link between hypertension in pregnancy and later A-fib after adjustment for obesity and hypertension. “But then, you know, there are all of these other things that we didn't necessarily hunt for,” she said. “There is maybe something else that goes in between as well.”

The reason a study like this would be important, she explained, is that women who develop hypertension in pregnancy often “go back to their OB for their follow-up visit, and if their blood pressure has come down to normal, they go . . . back to their usual life.” But research has shown that these women also have a high prevalence of later masked hypertension that might be missed, Scantlebury said, adding that further follow-up from a general practitioner could “nip this in the bud.”

She urged healthcare providers treating women with hypertension in pregnancy to take the opportunity to “sit down and talk with them and say, ‘OK, you are at risk of developing hypertension early on and at a higher rate than other women. So you need to keep following up with your GP, your primary care doctor. You need to be proactive in monitoring your blood pressure from the time this pregnancy ends. Don't wait 10 years post-pregnancy, 5 years post-pregnancy.”

It's all about knowing what the risks are, and if you have hypertension in pregnancy, I think that should raise red flags in everybody's minds that . . . if you have hypertension in pregnancy, you are going to get a cardiovascular complication at some point. Dawn Scantlebury

In her practice in Barbados, patients have “very high blood pressure and a high prevalence of hypertension,” Scantlebury said. “I know that if these people had been diagnosed a lot earlier and treated a lot earlier, I wouldn't see as much heart failure. So it's all about knowing what the risks are, and if you have hypertension in pregnancy, I think that should raise red flags in everybody's minds that . . . if you have hypertension in pregnancy, you are going to get a cardiovascular complication at some point. It's not 100%, but this is how we need to operate and look for that cardiovascular complication.”