Lupus Linked With Greater Risk of Cardiovascular Complications of Childbirth

Pregnant women with systemic lupus erythematosus (SLE) were more prone to cardiovascular complications during delivery, and their risk seems to have increased over the past 15 years, according to national administrative data.

The cross-sectional study supports the role that the underlying inflammatory activity of SLE may play in these cardiovascular complications, since even after adjustment for cardiometabolic risk factors, SLE remained an independent predictor of the following adverse events during delivery hospitalization:

• Preeclampsia: adjusted odds ratio 2.12 (95% CI 2.07-2.17)
• Peripartum cardiomyopathy: adjusted OR 4.42 (95% CI 3.79-5.13)
• Heart failure: adjusted OR 4.06 (95% CI 3.61-4.57)
• Cardiac arrhythmias: adjusted OR 2.06 (95% CI 1.94-2.21)
• Stroke: adjusted OR 4.83 (95% CI 4.18-5.57)
• Venous thromboembolism: adjusted OR 6.90 (95% CI 6.11-7.80)

For this study, Erin Michos, MD, of Johns Hopkins Hospital in Baltimore, and colleagues probed the U.S. National Inpatient Sample (NIS) database and analyzed over 63 million delivery hospitalizations from 2004 and 2019.

“Our findings suggest that a multidisciplinary approach to treatment of pregnant patients with SLE in liaison with a rheumatologist, a cardiologist, and an obstetrician may be associated with improved outcomes,” they stated in JAMA Network Open.

“To our knowledge, our study provides the most recent data on population-level trends of SLE at pregnancy delivery that have not been described before and may warrant an urgent public health intervention,” they said, adding that maternal mortality is rising in the U.S.

The link between SLE and cardiovascular risk in pregnancy had been documented in several studies. Previous work showed that a chronic inflammatory state is associated with increased risk for preeclampsia and long-term cardiovascular events after childbirth.

Now the present study extends the evidence to acute peripartum cardiovascular events, according to Michos and colleagues.

They cautioned that their dataset lacked important variables such as use of medications, gestational age at delivery, previous history of preeclampsia, and severity of SLE. The observational analysis also precluded any causal associations between SLE and cardiovascular complications of childbirth.

Given these and other limitations of the study, Jill Buyon, MD, of NYU Langone Health in New York City, told MedPage Today that it is important to take the results in context.

Buyon, who was not involved with the study, suggested that clinicians should not be overly negative about the observed cardiovascular risks to patients with SLE and should instead continue to emphasize disease stability and even remission as part of pregnancy counseling. More studies addressing clinical risk factors and biomarkers are ongoing, she noted.

Michos’ group performed a retrospective analysis of NIS data collected from 47 U.S. states and the District of Columbia.

Out of the large sample of delivery hospitalizations, just 0.1% were for women with SLE (median age 28). Patients in this subgroup tended to be slightly older than the rest, and were more likely to be Black and have preexisting comorbidities such as polycystic ovary syndrome, gestational diabetes, obesity, and dyslipidemia.

These cardiometabolic risk factors generally increased in prevalence over the study period from 2004 to 2019.

Over those 15 years, the prevalence of SLE also increased (from 98 to 148 hospitalizations per 100,000 deliveries, P<0.01), as did acute peripartum cardiovascular complications in the SLE subgroup (from nearly 2,000 to 6,000 in 100,000 deliveries, P<0.01).

“It may be postulated that the increased prevalence of cardiometabolic risk factors may be associated with the use of steroids in these patients, which has been shown to be associated with a 2-fold higher risk of CV [cardiovascular] events,” according to Michos’ group.

“It is important to note that prior studies evaluating the association of immunosuppressive medications with CV complications have found conflicting results, with some suggesting that reducing lupus inflammatory activity may be associated with beneficial outcomes, while others found that these medications were associated with higher rates of CV complications in the long term,” they noted.