Cardiovascular events 18 times more common in pregnant patients with lupus, APS
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SAN DIEGO — Pregnant patients with concomitant systemic lupus erythematosus and antiphospholipid syndrome have an 18-fold increased risk for cardiovascular events vs. healthy pregnant controls, said a speaker at ACR Convergence 2023.
“It is known that autoimmune rheumatic diseases and pregnancy both increase the risk of cardiovascular events,” Rashmi Dhital, MD, of the University of California, San Diego, told Healio. “However, there is limited research focused on the impact of autoimmune rheumatic diseases on cardiovascular event risk during pregnancy and early postpartum.”
Dhital added that comparisons between different diseases across the rheumatology spectrum focusing on cardiovascular outcomes during pregnancy are lacking.
“We conducted this study to gain a comprehensive understanding of the extent of cardiovascular event risks in autoimmune rheumatic diseases, focusing on the specific population of pregnant individuals,” she said. “To place our findings in context, we also looked at similar cardiovascular event risks in another autoimmune condition, primary antiphospholipid syndrome (APS), known to be associated with cardiovascular risks and events.”
To this end, Dhital and colleagues compared the outcomes of 19,340 pregnant women with autoimmune rheumatic diseases vs. the general population of pregnant women with no autoimmune rheumatic conditions. Eligible participants were those who delivered singleton liveborn infants in California between 2005 and 2020. Data linking birth certificates to maternal hospital discharges and emergency department and ambulatory surgery records were sourced from the California Study of Outcomes in Mothers and Infants.
Cardiovascular events reported up to 6 weeks postpartum, identified via ICD codes, were included in the analysis. Autoimmune rheumatic diseases and APS were similarly identified using ICD codes. The researchers used logistic regression to calculate adjusted RRs, as well as mediation analysis to determine if pregnancy complications, including gestational diabetes mellitus and pre-eclampsia, impacted the association between autoimmune rheumatic diseases and cardiovascular events.
Among the included patients with autoimmune rheumatic diseases, 7,758 had APS. The control group, meanwhile, included more than 7 million pregnant patients without any autoimmune rheumatic condition.
Results showed that cardiovascular events occurred in 2% of pregnant women with autoimmune rheumatic diseases, as well as in 6.9% those with primary APS, and in 0.4% of the healthy controls.
Compared with the general population of pregnant women, the risk for acute cardiovascular events was significantly greater in pregnant women with autoimmune and rheumatic diseases (aRR = 4.1; 95% CI, 3.7-4.5) and primary APS (aRR = 14.7; 95% CI, 13.5-16.0), according to the researchers.
“Patients with autoimmune rheumatic diseases have higher frequencies of traditional cardiovascular risk factors and a four-fold higher risk of cardiovascular events,” Dhital said.
Cardiovascular events were more than six times as likely in women with SLE compared with the general population. The risk in this group was further elevated by the presence of concomitant APS (aRR = 18.1) or nephritis (aRR = 12.7).
Further investigation revealed that 12% of excess risk for acute cardiovascular events in the autoimmune rheumatic disease group was mediated by preeclampsia, while fewer than 1% of events were mediated by gestational diabetes mellitus, according to the researchers.
In addition, evaluation of readmission records demonstrated that approximately 25% to 30% of cardiovascular events occurred postpartum. The researchers noted that this rate was six times higher in the autoimmune rheumatic disease group compared with controls.
“Since about a quarter of cardiovascular events occurred in early postpartum in our study, close follow-up and continued vigilance even after delivery is needed,” Dhital said.
“Future studies should focus on cardiovascular event risk stratification, exploring patient, disease, and treatment-specific characteristics contributing to elevated cardiovascular event risk, and investigating the effects of medications and other preventative strategies to reduce this risk,” she added.
Additional studies are also needed to understand the broader implications of cardiovascular events on adverse pregnancy outcomes, and later disease risk in children and adults, according to Dhital. She added that strategies to effectively monitor and manage cardiovascular risks and events in rheumatology patients should be developed.
“This should include disease-specific cardiovascular risk screening and management guidelines, exploration of biomarkers, cost-effective imaging, and practice enhancements like electronic health records alerts,” Dhital said. “Adding cardiovascular risk screening and management to existing American College of Rheumatology reproductive health guidelines would benefit our patients who are pregnant or considering pregnancy.”
Individual rheumatologists play a role in helping patients with these complications, as well. “Managing traditional risk factors, which are more prevalent in autoimmune rheumatic diseases and primary APS, may help mitigate some of the risk of maternal cardiovascular events in these groups,” Dhital said. “Maternal cardiovascular risks varied by disease and were higher even after adjusting for traditional risk factors, indicating the importance of considering individual patient profiles, disease, and treatment-related factors to tailor care.
“Since diagnosis may be challenging due to lower suspicion for cardiovascular events in younger patients, and symptoms overlap with normal pregnancy, rheumatologists should collaborate with other health care teams such as obstetrics and cardiology to manage this important complication,” she added.
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Dhital R. Abstract 722. Presented at: ACR Convergence 2023; Nov. 10-15, 2023; San Diego.
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