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cardiovascular disease

What is the ‘safe’ timing of surgery after an ischaemic stroke?

Time elapsed after ischaemic stroke and risk of adverse cardiovascular events and mortality following elective non-cardiac surgery

 Journal of the American Medical Association. 2014;312(3):269-277

 Presented by: Dr Anthony Byford-Brooks

Background

  • Cerebrovascular accident (CVA) is recognised as a major risk factor for major adverse cardiac event (MACE) following non-cardiac surgery. It is included in the Lee revised cardiac risk index, and is also analogous to the perioperative risk to patients with recent myocardial infarction (MI) +/- percutaneous coronary intervention (PCI). The ‘safe’ timing of surgery post-CVA is not well defined like it is with MI.
  • Cerebral autoregulation is known to be impaired up to 90 days following CVA, but the significance of this in the perioperative setting, and the impact of surgery and anaesthesia on autoregulation is not well studied.
  • This study aimed to look at safety and importance of time between stroke and surgery.

Design & Setting

  • A retrospective, Danish nationwide cohort study from 2005-2011.
  • All patients above 20 years of age undergoing elective non-cardiac surgery (n=481,183).
  • Danish healthcare system keeps all information on national registries, and five were accessed in order to gather data on patient backgrounds, types of surgeries, medicines used and anaesthetic records.

Subjects

  • All patients over 20 years of age having elective non-cardiac surgery from 2005-11. ICD-10 used to identify those patients who suffered ischaemic stroke in the past. Haemorrhagic stroke and TIA were excluded. Stroke diagnosis excluded if time elapsed to surgery >5yrs.
  • Five population groups, made to be roughly analogous with post-MI risk:
    1. No prior stroke
    2. Stroke ❤ months of surgery
    3. Stroke 3-6 months of surgery
    4. Stroke 6-12 months of surgery
    5. Stroke >12 months of surgery
  • Grouping for use of pharmacological agents based on use of antihypertensives, antithrombotics, oral hypoglycaemics and diuretics.
  • Significant comorbidities included organ failures, AF, IHD, COPD, PVD, anaemia, DM and metastatic disease
  • Surgery performed subdivided by specialty, excluding trauma, intracranial surgery, tracheostomy/gastrostomy and urgent upper GI. Also grouped into low, intermediate and high risk surgeries.

Outcomes

  • Primary outcomes were all-cause mortality and MACE within 30 days.
  • MACE subdivided into nonfatal acute MI, nonfatal ischaemic stroke and cardiovascular death.

Results

  • Of the 481,183 surgeries performed, 7137 (1.5%) were performed in patients with prior history of stroke.
  • These patients were on average 16 years older, male, on cardiovascular meds and had more comorbidities.
  • Almost a quarter of the stroke and non-stroke group had >1 surgery in the 5 year period.
  • Incidence rates (Stroke vs. Non-stroke group):
    • Ischaemic stroke: ❤ months – 149.6x higher
    • All-cause mortality: ❤ months – 12.6x higher
  • Odds Ratios:
    • 30-day MACE (<3months vs >12 months): 14.23 vs 2.47
    • Low (9.96), Intermediate (17.12) and Higher (2.97)
    • Recurrent strokes ❤ months: 67.6
    • No association between prior stroke and acute MI
    • Cardiovascular death: 4.35
    • Splines for OR levelled off roughly after 9 months.
    • Alcohol and smoking as covariates altered OR very little.
    • Use of blood-thinning agents and statins has a significant impact in reducing risk.
  • Relative Risk:
    • 30-day mortality: 1.8-fold increased risk in stroke group.
    • 30-day MACE: 4.8-fold increased risk in stroke group.
  • Stroke patients with AF at less risk than those without AF.
  • Those with recurrent strokes at higher risk.

Conclusions

  • Elective non-cardiac surgery <9 months after stroke carries significant risk of MACE and mortality.
  • Low or intermediate surgery carries equal or higher relative risk than high-risk surgery.
  • Patients with AF have lower risk perhaps due to nature of stroke (thrombotic vs atherosclerotic) and higher likelihood of subsequently being on appropriate drugs. 

Strengths

  • Good access of the Danish databases to address a question not previously asked.
  • Large cohorts.
  • Use of data analysis that helps quantify risk over a protracted period.
  • Consideration of additional factors (drug history, comorbidities).
  • Authors identify study weaknesses.

Weaknesses

  • No data on whether surgeries performed took time elapsed from stroke into consideration.
  • Patients may not have been fully worked up or optimised prior to surgery, particularly those <3months of stroke e.g. echo.
  • No data on in-hospital drug administration, only long-term meds at home
  • Undiagnosed comorbidities would skew data.
  • Guidelines for perioperative use of antithrombotics in Denmark changed during study period.
  • Not able to determine if ischaemic stroke is embolic or atherosclerotic e.g. AF vs PVD.
  • Type and conduct of anaesthesia not accounted for.

Implications

Although stroke is known to be a risk factor, a way of quantifying risk based on time since event, as well as what patient factors adjust this risk, can improve patient safety. The timing is similar to acute-MI +/- PCI for those at highest risk, but some risk does remain up to 9 months.

Potential for Impact

There is a potential for impact here. A forming evidence base on the degree of risk following stroke could help mitigate adverse events by allowing for optimisation of patients following stroke, or delaying of surgery, particularly those of lower risk. It also gives food for thought for emergency surgery and highlights the need for a detailed history of CVA and informed discussion on perioperative risk for those patients.

Does a cardiology review make a difference before major vascular surgery?

The Clinical Impact of Cardiology Consultation Prior to Major Vascular Surgery

Annals of Surgery 2018, 267 (1): 189-195. doi: 10.1097/SLA.0000000000002014.

 Presented by: Dr S O’Beirn

Background

  • Cardiovascular complications are the leading cause of morbidity and mortality in adult patients undergoing major vascular surgery.
  • Despite the perceived benefit of preoperative Cardiology consultation in high risk patients the evidence for this and the guidance for which patients it would be of greatest benefit remain unclear.
  • This study aims to analyse the impact of pre-operative Cardiology consultation rates on the incidence of post-operative Myocardial Infarction (MI) at the individual and Hospital level.

 Design & Setting

  • Retrospective analysis of a large prospective multicentre observational registry based in 29 hospitals across the state of Michigan from Jan ’12 to Dec ’14.

Subjects

  • 5191 cases undergoing Open Peripheral Arterial Bypass (n=3037), Open Abdominal Aortic Aneurysm Repair (n=332) or Endovascular Aneurysm Repair (n=1822).
  • Cases excluded Emergency surgery, Carotid Endarterectomy or Stenting, Age <18 or BMI <10 or >80.

Intervention

  • Preoperative Cardiology consult defined as a documented Cardiology clinic or In hospital consultation within 6 months prior to the procedure.

Outcomes

  • Primary Outcome of Perioperative Myocardial Infarction (PoMI) defined as a rise in cardiac biomarkers combined with either Ischaemic symptoms, new Ischaemic ECG changes, pathological Q waves or Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality.
  • Secondary Outcomes included the development of a dysrhythmia, congestive heart failure or cardiac arrest within the initial hospitalisation following the operation.

Results

  • Patients undergoing pre-operative Cardiology consultations had significantly higher rates of Perioperative MI (2.7% vs 1.47%, p=0.002).
  • No significant variation in mortality (1.57% vs 1.10%, p=0.147).
  • Huge variation in rates of Cardiology consultation across centres (6.9%-87.5%, median 53.3%).
  • Lower rate of Perioperative MI at the quartile of centres with the highest rate of consultations OR 0.52 (0.27-0.98, 95% CI, p=0.045).

Conclusions

  • Higher rate of PoMI amongst patients undergoing pre-operative Cardiology consultation, though this can likely be explained by these patients being at higher risk due to operative and patient factors.
  • No significant variation in rates of PoMI within quartiles when cases grouped according to Revised Cardiac Risk Index.
  • Reduction of PoMI seen in hospitals with higher rates of preoperative Cardiology consultation. The specific mechanism of this is unclear. Suggestion of “Hospital culture” as a factor.

Strengths

  • Large sample size at the patient level.
  • Reporting of negative results.
  • Clinically relevant question.

Weaknesses

  • Retrospective analysis of previously published data.
  • Acknowledged limited data on the outcome of preoperative consultations.
  • Significant cofounders unaccounted for (Intraoperative anaesthetic and fluid management, technical skill of the surgeon, critical care management).
  • Lack of cost analysis.
  • Potential for lack of generalisability given all centres within 1 state.
  • Significant inter-quartile variability within rates of PoMI among centres with low rates of preoperative consultation.
  • Multiple implications drawn from lower rates of PoMI amongst high preoperative consultation centres despite only just attaining significance at a 95% CI (p=0.045).

Implications

  • Based on this study, centres with higher rates of preoperative medical consultation have lower rates of perioperative complications, specifically perioperative MI amongst patients undergoing elective major Vascular surgery.
  • However, this is not demonstrated by this data on a patient level and the implication is that variation in hospital culture is a key confounder.

Potential for impact

  • Limited potential for impact as failure to demonstrate improvements in perioperative outcomes on the patient level and lack of suggestion as to which patient groups may benefit from undergoing preoperative consultation.

 

February 2018

Written by Dr. C. Williams

Comparison of 4 cardiac risk calculators in predicting postoperative cardiac complications after non cardiac operations. Cohn S, Ros NF. The American Journal of Cardiology 2017 doi:10.1016/j.amjcard.2017.09.031

Identifying patients who are at high-risk of perioperative complications is something that we are still trying to refine. There are many risk calculators available to try to identify all kinds of risk – ranging from cardiovascular risk, risk of acute kidney injury, risk of post-operative cognitive dysfunction, risk of mortality and so on. Trying to work out which is the best risk calculator to use can seem like trying to negotiate your way through a minefield.

We know that cardiovascular complications after non cardiac surgery are an important cause of postoperative morbidity and mortality. One can use different risk calculators and get different estimates of the patients risk but which is the most reliable risk predictor? This is a question this paper tries to answer by looking at 4 different cardiac risk calculators.

Trying to identify high risk patients is not a new phenomenon – the first cardiac risk index was published by Goldman et al. in 1977. This was followed in 1999 by Lee at al publishing the revised cardiac risk index (RCRI). In 2013 Davies et al. improved prediction using a 5 factor reconstructed RCRI (R-RCRI). The 2014 ACC/AHA guidelines on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery recommended using the RCRI or two newer tools created from the National Surgical Quality Improvement Program (NSQIP) database – namely the myocardial infarction or cardiac arrest (MICA) calculator or the American College of Surgeons surgical risk calculator (ACS-SRC).

Essentially this paper found that all 4 risk calculators performed well at defining low and elevated risk groups but tended to slightly underestimate cardiac events. There are two salient points made:

  1. The definitions for outcomes and timeframes used to develop the risk calculators are different therefore a valid direct comparison of outcomes is not possible
  2. If the risk calculators are used in a manner different from the way derived they do not perform as well

Ultimately risk calculators give an estimate of risk – it is not a black/white answer as to whether that patient will develop that particular complication. What they are useful for is to facilitate shared decision making discussions with patients and enable them to make an informed decision regarding their treatment choice.

Postoperative ERAS interventions have the greatest impact on optimal recovery: Experience with implementation of EAS across multiple hospitals. Aarts M, Rotstein O, Pearsall E metal on behalf of the iERAS group. Annals of Surgery 2018 doi:10.1097/SLA.0000000000002632 

ERAS (Enhanced recovery after surgery) pathways use evidence-based practices to minimise perioperative stress and promote early recovery. These multimodal care pathways incorporate multiple interventions within the preoperative, intraoperative and postoperative course of the patient’s perioperative journey. Multiple papers have been published which demonstrate that ERAS benefits patients when compared to standard care and show a decreased rate of complications, accelerated recovery and earlier discharge from hospital.

But while ERAS has been shown to be effective at improving outcomes, it can be difficult to implement not least because it requires a sustained collaborative effort from members of a multidisciplinary team. This paper aims to determine which component of ERAS has the largest impact on recovery for patients undergoing colorectal surgery and also to look at the relative benefits of ERAS in laparoscopic versus open surgery.

Of the 2876 patients studied only 20.1% had care that was compliant with all phases of the pathway. The poorest compliance was for the postoperative interventions yet these were the interventions most strongly associated with an optimal recovery. Compliance with ERAS was associated with improved outcomes regardless of whether surgery was open or laparoscopic. However, the impact of ERAS compliance was significantly greater in patients having open surgery.

In addition to the ERAS components two other potentially modifiable factors were found to significantly impact on patient outcomes namely operative technique and preoperative haemoglobin levels.

Maybe it is time to go back and reassess how ERAS is implemented. My view as an anaesthetist is that it seems that more emphasis is placed on the preoperative and intraoperative parts of the pathway – the question is whether this is because that is what happens or because those are the parts of the pathway that anaesthetists are more involved with? There is plenty of emerging evidence that postoperative care is as important as other parts of the pathway and if the results of this study are valid then it would seem that postoperative interventions make the most difference to patient outcomes. Once again this paper adds to the increasing body of evidence that as anaesthetists it may have come to the time that we need to step up to the mark and pay more attention to postoperative care. After all, why take so much care making sure our patients are as pre-optimised as possible and given the best intraoperative care if we do not follow this through to the postoperative phase?

Preoperative geriatric assessment and tailored interventions in frail older patients with colorectal cancer: a randomised controlled trial. Ommundsen N, Wyller TB, Nesbakken A et al. Colorectal Disease 2018 doi:10.111/codi.13785

The role of comprehensive geriatric assessment for older patients undergoing surgery is much discussed in the literature at the moment. Geriatric assessment and input has already been shown to make a difference and improve functional status in hip fracture patients. This paper aimed to looks at whether a preoperative geriatric assessment can identify older patients at risk of developing postoperative complications after surgery for colorectal cancer. Patients over the age of 65 years scheduled for elective colorectal cancer surgery and fulfilling criteria for frailty were randomised to either a preoperative geriatric assessment and a tailored intervention (based on the assessment) or usual care.

The findings of this paper were that a geriatric assessment and tailored intervention made no difference to the rate of complications or to the secondary endpoints of median length of stay, discharge to own home, need for readmittance or reoperation within 30 days or 30 day and 3 month mortality.

In my opinion there are significant limitations to the data in this study – despite running for a long period of time (2011 – 2014) only 122 patients were recruited and consequently the study is probably underpowered (acknowledged by the authors). Also, the optimal time from intervention to surgery was hypothesised to be 3 weeks – which seems a short time period for an intervention to make a significant difference to outcome. Furthermore the authors go on to detail that the actual time for pre optimisation was a median of 6 days. Additional evidence is needed to be able to draw conclusions as to the effectiveness of geriatric assessment on patient outcomes particularly given that geriatric input has been shown to be efficient in other surgical settings.

Does goal-directed haemodynamic and fluid therapy improve peri-operative outcomes? A systematic review and meta-analysis. Chong MA, Wang Y, Berbenetz NM, McConchie I. European Journal of Anaesthesiology 2018;35:1-15 doi:10.1097/EJA.0000000000000778 

There is much debate about the effectiveness of perioperative goal-directed haemodynamic and fluid therapy. The seminal study by Shoemaker et al published in 1988 demonstrated that patients receiving preoperative haemodynamic optimisation titrated to goals of end organ blood flow had improved outcomes. Since then there have been multiple randomised controlled trials looking at this. In my personal experience many anaesthetists have quite polarised views on the efficacy of goal directed therapy.

The authors carried out a systematic review and meta analysis of 95 randomised controlled trials where goal directed therapy was studied defined as fluid and/or vasopressor therapy titrated to haemodynamic goals. The findings of this comprehensive review demonstrate that goal directed therapy modestly improves mortality in non-trauma and non pregnant adult surgical patients. The authors suggest that based on the articles included for analysis, the numbers suggest tat for every 1000 patients treated with goal directed therapy, 18 deaths would be prevented.

However, the quality of evidence was low to very low with much clinical heterogeneity among the goal-directed therapy devices and protocols. This is likely to be an area of continuing interest for perioperative research and further well designed and adequately powered trials are needed. Hopefully the OPTIMISE-II and FLO-ELA trials may answer some of the questions surrounding goal directed therapy.

Clinical guideline and recommendations on pre-operative exercise training in patients awaiting major non-cardiac surgery. New GA, Ayyash R, Danjoux GR. Anaesthesia 2018 doi:10.1111/anae.14177

Pre-operative exercise has been much debated over the past few years. There have been several systematic reviews on the effects of pre-operative exercise with sufficient clinical trial data to support pre-operative exercise training as being safe and efficacious. But how exactly can one translate the evidence from clinical trials into clinical practice. This paper aims to provide practical and evidence-based guidelines on how to deliver pre-operative exercise training to patients awaiting major, non cardiac surgery.

Chronic physical inactivity accelerates age-associated declines in maximal aerobic capacity and functional fitness which consequently places individuals at increased risk of complications when undergoing major or complex surgery.

There are ten key recommendations which cover patient selection for exercise training in surgical patients, integration of exercise training into multi-nodal prehabilitation programmes and advice on exercise prescription factors and follow-up. This guideline also touches on the fact that successful implementation of rehabilitations programmes may prove challenging. A range of institutionalised cultural and attitudinal barriers exist that could affect pre-operative initiatives to a varying degree. System-related barriers include lack of educational opportunities highlighting the benefits of exercise, insufficient infrastructure and concerns about the feasibility of delivery and cost effectiveness of potential programmes. Several barriers to implementation are highlighted – the main ones being resistance to change from patients and staff and lack of funding or support from management.

Although the authors acknowledge that further research is needed to identify the optimal exercise prescription, this is a much needed clinical guidelines. Hopefully it will result in perioperative teams being able to incorporate pre-operative exercise training for patients into their routine practice.

Association between handover of anesthesia care and adverse postoperative outcomes among patients undergoing major surgery. Jones PM, Cherry RA, Allen BN et al. The Journal of the American Medical Association 2018;319(2):143-153 doi:10.1001/jama.2017.20040

This article looked at over 313000 patients to look at whether handing over of care from one anaesthetist to another during surgery is associated with a worse outcome. Given the shift work that many anaesthetists (particularly trainees) now work, handing over of care during surgery cannot always be avoided. Handovers may be temporary (initial clinician hands over care to another clinician for a break and then returns) or complete (care is completely handed over to another clinician). Handover is a potentially vulnerable time for the patient because all information required must be transferred between clinicians in a busy environment with many distractions. If crucial details are missed the patient may be at risk of an adverse event. The alternative theory is that a rested clinician taking over care from a fatigued clinician may improve the quality of care and reduce adverse events.

Complete intraoperative handover of care compared with no handover of care was associated with a higher risk of all-cause death, hospital readmission and major postoperative complications over 30 days (44% versus 29%). Intraoperative handovers were also associated with an increase in intensive care admissions and a longer hospital stay.

This is a topic which raises many questions. The authors note that in Canada the number of complete handovers of care is increasing each year. Fatigue and the effects that it has on performance at work is also much debated at the moment.* Knowing that fatigue exacerbates many human limitations, some departments have implemented policies of restricted duty hours for medical staff. It is likely that these policies have an impact on the number of handovers of care.

Given the increase in adverse events observed in this study, the public health implications are concerning. The most prudent approach would be to minimise unnecessary anaesthetic handovers. However the factor of fatigue cannot be ignored. At some point fatigue will have a measurable and detrimental effect on clinicians and handovers in this case would be reasonable. But the question of how to determine when the risk of a fatigued clinician exceeds the potential risk of a complete handover is not one that can currently be answered.

(*July 2017A national survey of the effects of fatigue on trainees in anaesthesia in the UK.  McClelland L, Holland J, Lomas J-P, Redfern N, Plunkett E. Anaesthesia 2017 doi:10.1111/anae.13965)

February 2017

Written by Dr C. Williams

Cardiac arrest, intubation and survival.  Journal of the American Medical Association 2017 doi:10.1001/jama.2016.20165

Since 2010, the importance of tracheal intubation during cardiac arrest in adults has become less important. The optimal approach for airway management during arrest is not clear. This was an observational cohort study of 86,628 adult patients who had an in-patient cardiac arrest between January 2000 to December 2014. Intubation within the first 15 minutes was associated with a lower chance of ROSC, lower survival to hospital discharge with reduced functional outcome. The authors of this study admit that it does not totally eliminate the potential for confounding. However, these findings do not support early tracheal intubation for adult in-hospital cardiac arrest.

 

Intraoperative monitoring of analgesia using nociceptive reflexes correlates with delayed extubation and immediate postoperative pain. European Journal of Anaesthesiology 2017;34:1-9 doi:10.1097/EJA.0000000000000597

Up to 50% of patient have moderate to severe pain immediately after surgery. Does it matter? Not only is it is unpleasant, it can cause hamemodynamic instability, impair wound healing and risk development of chronic pain with reduced mobility. Easy to avoid with long-acting analgesics at the end of surgery……but how to avoid overdosing, prolonged sedation and respiratory depression?

This study looked at the pupillary dilation reflex (PDR) and the nociceptive flexion reflex (NFR) of the biceps femoris. The PDR threshold (PDRT) and the NFR threshold (NFRT) were measured 1 week pre-operatively, then repeated  at the end of surgery. The PDRT and NFRT both correlate with immediate postoperative pain and the time to extubation.

How clinically relevant this is remains questionable. The authors admit the reflexes are of limited use except in clinical studies where clinical variability is reduced. Possibly something for the future?

 

Start2quit:a RCT. Effectiveness of personalised smoking cessation advice. Lancet 2017 doi:10.1016/S0140-6736(16)32379-0

The number of adults smoking in the UK has fallen by more than 50% since 1974, but this has slowed since 2007. The total direct cost to the NHS of smoking-related disease was estimated at £5.2 billion (2005-6). NHS Stop Smoking Services (SSS), established in 2000, effectively help and support smokers to quit with quit rates of about 35%. Despite this fewer than 5% of smokers attend each year – maybe due to the increasing popularity of e-cigarettes?

This study aimed to look at whether showing how smoking related to their individual risk of bad things happening works as motivation. Smokers aged 16 or over were randomly assigned to receive either an individually tailored risk letter and invitation to attend a non-commitment introductory SSS session (intervention group) or a standard generic letter advertising the local SSS group (control group).

Attendance at the SSS group was significantly higher in the intervention group (17.4% vs 9%) although still at the low rate expected for smoking cessation trials. (NB this was just the attendance at the initial SSS meeting and not the quit rate). Possibly a more proactive approach may reduce patient barriers to access treatment and increase uptake of cessation session?

 

Surgical Decision Making: Sharing Decisions……… Journal of the American Medical Association 2017;317(4):357-358 doi:10.1001/jama.2016.18719

Shared decision-making (SDM) is an approach in which clinicians and patients communicate together using the best available evidence when faced with the task of making decisions. It should be a collaboration in which the physician (in this case the surgeon) explains treatment options, elicits values from the patient and importantly guides the conversation towards a decision consistent with the patient’s values and current evidence. Three recent RCTs looked at surgical management in appendicitis, diverticulitis and knee osteoarthritis. The common factor in these studies is that they compared commonly used operations with significantly less aggressive than non-operative alternatives – importantly neither treatment option was superior. However, all studies showed that surgical treatment may be required later on.

Surgical dogma is being challenged – accepted treatment is shifting away from long-established surgical gold-standard treatments. But who and how should the decision be made? The patient-centred framework challenges the ‘one-size fits all’ model. One treatment option is rarely shown to improve outcomes for all important end-points. There are barriers: ‘Surgeons often lack the time or training to talk patients through these complicated trade-offs. They may have concerns about liability for untoward outcomes from unconventional treatments.’ What is clear is that SDM is here to stay and we must find a way to embrace this.

 

Editorial: The never-ending story of the elderly with fractured neck of femur. European Journal of Anaesthesiology 2017;34:115-117

What the literature tell us so far……..

  • In the UK, 30-day mortality is 8.5% – decreasing but still unacceptably high.
  • Hospital stays of <10 days are associated with increased survival 30 days after discharge.
  • 95% of hip-fracture patients have at least one major co-morbidity
  • Unsurprisingly the number of co-morbidities negatively influences the physical and psychological outcomes of patients.
  • Anaesthetic for hip-fracture surgery varies greatly – Regional techniques are associated with a shorter hospital stay but 30-day mortality is no different whether GA or regional anaesthesia is used.
  • Perioperative pain management with a multi-modal approach is vital – implementing fast-track care pathways and early surgery improves 30-day mortality rate.
  • Intraoperative haemodynamic stability seems to improve outcome
  • Anaemia is an independent risk factor for long-term mortality
  • Dedicated geriatric care leads to improved mobility at 4 months compared to standard orthopaedic care.

 

A couple of obs related studies…………

Number of pregnancies and atrial fibrillation risk: the Women’s health study. Circulation 2017 doi:10.1161/CIRCULATIONAHA.116.026629

  • This study followed 34,639 women for a median of 20.5 years
  • Having four or more pregnancies means you are 30-50% more likely to develop AF than nulligravida women
  • Possibly thought to be due to repeated exposure to physiological, metabolic or hormonal factors during pregnancy
  • Mainly European women in the study so may not be generalisable to all races or ethnicities

Preterm delivery and maternal cardiovascular disease in young and middle aged adult women. Circulation 2017 doi:10.1161/CIRCULATIONAHA.116.025954

  • Women who deliver their first child before 37 weeks gestation have a 40% greater risk of developing cardiovascular disease later in life.
  • If the baby was delivered before 32 weeks this doubled thee risk of later cardiovascular disease – even when adjusted for pre-eclampsia or gestational diabetes
  • In less than 25% of cases this increased risk was explained by hypertension, hypercholesterolaemia, type 2 diabetes and changes in body mass developing after the first birth.
  • Delivering a preterm infant could be an early warning signal of a high risk for cardiovascular disease

It’s never too early to adopt a heart healthy lifestyle……should we be warning women??

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