Long-term cardiovascular morbidity and mortality after maternal heart failure: a nationwide population-based cohort study
C Kihlborg, J Faxen, A MantelAbstract
Introduction
Maternal heart failure is a rare but sserious complication of pregnancy associated with substantial short-term morbidity and mortality. While its incidence has increased over time, knowledge regarding long-term cardiovascular outcomes remains limited with previous studies based on small cohorts and short follow-up.
Purpose
To investigate long-term cardiovascular morbidity and mortality among women with a history of maternal heart failure during pregnancy or the postpartum period.
Methods
This nationwide population-based cohort study was conducted through linkage of Swedish national health registers, including the Medical Birth Register, National Patient Register, and Cause of Death Register. Women with no previous cardiovascular disease giving birth in Sweden between 2000 and 2019 with incident maternal heart failure occurring during pregnancy or within one year postpartum were identified (n=703) and matched with heathy controls (1:10) by maternal age, year of delivery, region, and parity (n=7030). The primary outcomes were all-cause mortality and rehospitalization for major adverse cardiovascular events (MACE), defined as heart failure, arrhythmias, cardiomyopathies, ischemic heart disease, pulmonary hypertension, or cerebrovascular events. Participants were followed from incident maternal heart failure diagnosis until primary event, death or 31 December 2020. Hazard ratios (HRs) with 95% confidence intervals (CI) were estimated using Cox proportional hazard regression, adjusted for maternal age.
Results
During a median follow-up time of 9 years (IQR 5-14), women with prior maternal heart failure experienced substantially higher rates of adverse outcomes compared with matched controls. A total of 19 deaths occurred in the heart failure group versus 35 among controls, corresponding to incidence rates of 2.9 and 0.5 per 1000 person-years, respectively, yielding an adjusted HR of 5.6 (95% CI 3.2-9.7). Cardiovascular complications were markedly more frequent among women with previous maternal heart failure, with 24 MACE-related hospitalizations compared with 10 events among controls (incidence rates 3.8 vs 0.1 per 1000 person-tears), corresponding to an HR of 24.8 (95% CI 11.9-51.8).
Conclusions
Maternal heart failure is associated with a profound and persistent increase in long-term cardiovascular risk. Women affected by maternal heart failure demonstrated markedly elevated risks of both mortality and major cardiovascular morbidity extending up to one decade following the initial diagnosis. These findings highlight maternal heart failure as a high-risk cardiovascular condition warranting long-term surveillance and cardiovascular follow-up beyond the peripartum period.1. Kaplan–Meier survival after maternal HF2. MACE after maternal HF