P-wave duration changes and dispersion in preeclampsia

The Role of Helicobacter pylori and Metabolic Syndrome-Related Mast Cell Activation Pathologies and Their Potential Impact on Pregnancy and Neonatal Outcomes

Helicobacter pylori infection, a significant global burden beyond the gastrointestinal tract, has long been implicated in various systemic pathologies. Rising evidence suggests that the bacterium's intricate relationship with the immune system and its potential to induce chronic inflammation impact diverse pathophysiological processes in pregnant women that may in turn affect the incidence of several adverse pregnancy and neonate outcomes. Helicobacter pylori infection, which has been linked to metabolic syndrome and other disorders by provoking pericyte dysfunction, hyperhomocysteinemia, galectin-3, atrial fibrillation, gut dysbiosis, and mast cell activation pathologies, may also contribute to adverse pregnancy and neonatal outcomes. Together with increasing our biological understanding of the individual and collective involvement of Helicobacter pylori infection-related metabolic syndrome and concurrent activation of mast cells in maternal, fetus, and neonatal health outcomes, the present narrative review may foster related research endeavors to offer novel therapeutic approaches and informed clinical practice interventions to mitigate relevant risks of this critical topic among pregnant women and their offspring.

Pregnancy-Related Complications and Incidence of Atrial Fibrillation: A Systematic Review

Pregnancy-related complications are associated with a higher risk of various incident cardiovascular diseases, but their specific potential relationship with incident atrial fibrillation (AF) is less clear. This systematic review summarises the available evidence from observational studies which have examined associations between pregnancy-related complications and the risk of AF. MEDLINE and EMBASE (Ovid) were searched for studies between 1990 to 10 February 2022. Pregnancy-related complications examined included hypertensive disorders of pregnancy (HDP), gestational diabetes, placental abruption, preterm birth, small-for-gestational-age and stillbirth. Study selection, data extraction and quality assessment were completed independently by two reviewers. Narrative synthesis was used to evaluate the results of the included studies. Nine observational studies were included, with eight eligible for narrative synthesis. Sample sizes ranged from 1839 to 2,359,386. Median follow-up ranged from 2 to 36 years. Six studies reported that pregnancy-related complications were associated with a significantly increased risk of incident AF. Hazard ratios (HRs) (95% confidence intervals) for the four studies that evaluated HDP ranged from 1.1 (0.8-1.6) to 1.9 (1.4-2.7). For the four studies that evaluated pre-eclampsia, HRs ranged from 1.2 (0.9-1.6) to 1.9 (1.7-2.2). Current evidence from observational studies suggests pregnancy-related complications are associated with a significantly higher risk of incident AF. However, only a small number of studies examining each pregnancy-related complication were identified, and considerable statistical heterogeneity was observed. Further large-scale prospective studies are required to confirm the association between pregnancy-related complications and incident AF.

Association of Number of Live Births With Electrocardiographic and Cardiac Structural Changes

Background Pregnancy is a major life event unique to women and leads to significant hemodynamic, hormonal, and metabolic changes. The purpose of this study was to use the DHS (Dallas Heart Study), a multiethnic population-based cohort study of Dallas county adults, to evaluate the association between number of live births and cardiac magnetic resonance imaging and ECG parameters later in life. Methods and Results Women were included if they had data on self-reported live births and ECG or cardiac magnetic resonance imaging measurements. The 3014 women were stratified by number of live births: 0, 1, 2, 3, 4, and ≥5. Higher number of live births was associated with larger left ventricular (LV) end-diastolic volume (β, 1.31±0.41; P<0.01), LV end-systolic volume (β, 0.83±0.24; P<0.01), and LV mass (β, 1.13±0.49; P=0.02) and lower LV ejection fraction (β, -0.004±0.0014; P<0.01). Increasing parity was associated with longer PR intervals (β, 1.07±0.38; P<0.01). Subgroup analysis by race demonstrated that the association between number of live births and magnetic resonance imaging parameters (LV end-diastolic volume, LV end-systolic volume, and LV ejection fraction) only remained significant in Black women (P value for interaction <0.05). Conclusions Increasing number of live births was associated with electrocardiographic and cardiac structural changes in a multiethnic population. When stratified by race and ethnicity, magnetic resonance imaging structural changes only remained significant in Black participants. Whether these changes are pathologic and increase the risk of heart failure or arrhythmias in multiparous women warrants further investigation.

Increased Cardiac Arrhythmia After Pregnancy-Induced Hypertension: A South Korean Nationwide Database Study

Background

Although pregnancy‐induced hypertension (PIH) is associated with an elevated cardiovascular risk, long‐term studies or prepregnancy baseline data are scarce. Therefore, using a large nationwide cohort with prepregnancy periodic health screening data, we investigated whether clinically significant arrhythmia incidence increases after PIH.

Methods and Results

Data were extracted from the Korea National Health Insurance database and combined with the National Health Screening Examination database; women who gave birth between 2007 and 2015 and underwent the national health screening test within a year before pregnancy were followed up until 2016. We excluded women who had a diagnosis of arrhythmia within 1 year before pregnancy. The primary outcome was significant arrhythmia during the year after delivery. Secondary analysis included only specific diagnostic codes of arrhythmia with clinical significance. Additionally, the risk of arrhythmia was stratified by the use of magnesium sulfate. Of 2 035 684 women (PIH; n=37 297 versus normotensive pregnancy; n=1 998 387), the PIH group had a higher prepregnancy risk profile and showed a higher incidence of arrhythmia than women with normotensive pregnancies within 1 year. Women with PIH had a significantly higher risk of atrial flutter/fibrillation and atrioventricular block, but not lethal arrhythmias. Other predictors of arrhythmia development included advanced maternal age and cesarean section. Stratified analysis showed a higher risk of arrhythmia with magnesium sulfate use.

Conclusions

PIH was significantly associated with the development of arrhythmia within 1 year after delivery. Nevertheless, the incidence of lethal arrhythmias was not increased by PIH. Arrhythmia, especially atrial fibrillation, may largely contribute to increasing the future cardiovascular risk in women with a PIH history.

Revealing the Influences of Sex Hormones and Sex Differences in Atrial Fibrillation and Vascular Cognitive Impairment

The impacts of sex differences on the biology of various organ systems and the influences of sex hormones on modulating health and disease have become increasingly relevant in clinical and biomedical research. A growing body of evidence has recently suggested fundamental sex differences in cardiovascular and cognitive function, including anatomy, pathophysiology, incidence and age of disease onset, symptoms affecting disease diagnosis, disease severity, progression, and treatment responses and outcomes. Atrial fibrillation (AF) is currently recognized as the most prevalent sustained arrhythmia and might contribute to the pathogenesis and progression of vascular cognitive impairment (VCI), including a range of cognitive deficits, from mild cognitive impairment to dementia. In this review, we describe sex-based differences and sex hormone functions in the physiology of the brain and vasculature and the pathophysiology of disorders therein, with special emphasis on AF and VCI. Deciphering how sex hormones and their receptor signaling (estrogen and androgen receptors) potentially impact on sex differences could help to reveal disease links between AF and VCI and identify therapeutic targets that may lead to potentially novel therapeutic interventions early in the disease course of AF and VCI.

Cardiac electrical and structural alterations in preeclampsia

BACKGROUND

Preeclampsia increases the risk of cardiovascular mortality and morbidity both during pregnancy and long term after the labor by causing cardiac changes that may lead to atrial and ventricular arrhythmias.

OBJECTIVE

We aimed to investigate noninvasive predictors of atrial and ventricular arrhythmias and cardiac structural changes in preeclampsia.

METHODS

The study included 34 preeclampsia patients as the study group and 33 healthy pregnant women as the control group. The presence of fragmented QRS morphology, P dispersion, QT dispersion, Tp-e/QTc ratio, inter- and intra-atrial electromechanical delay, left ventricular mass index was evaluated in the groups by 12 lead- ECG and standard and tissue Doppler echocardiography.

RESULTS

Left ventricular mass index and relative wall thickness, and E/Em ratio was significantly higher in preeclampsia. Inter- and intra-atrial electromechanical delay and Tp-e were prolonged, and P dispersion, QT dispersion, and Tp-e/QTc ratio were increased significantly in patients with preeclampsia. In addition, fragmented QRS morphology was seen in 76.5% of patients with preeclampsia while it was present in only 27.3% of the control group (p < .001).

CONCLUSION

Preeclampsia causes significant cardiac structural and electrocardiographic alterations that may increase the risk of atrial and/or ventricular arrhythmias. A more thorough and earlier cardiac assessment and closer follow-up of these patients would be useful to avoid further complications.

Assessment of Hypertension Using Clinical Electrocardiogram Features: A First-Ever Review

Hypertension affects an estimated 1.4 billion people and is a major cause of morbidity and mortality worldwide. Early diagnosis and intervention can potentially decrease cardiovascular events later in life. However, blood pressure (BP) measurements take time and require training for health care professionals. The measurements are also inconvenient for patients to access, numerous daily variables affect BP values, and only a few BP readings can be collected per session. This leads to an unmet need for an accurate, 24-h continuous, and portable BP measurement system. Electrocardiograms (ECGs) have been considered as an alternative way to measure BP and may meet this need. This review summarizes the literature published from January 1, 2010, to January 1, 2020, on the use of only ECG wave morphology to monitor BP or identify hypertension. From 35 articles analyzed (9 of those with no listed comorbidities and confounders), the P wave, QTc intervals and TpTe intervals may be promising for this purpose. Unfortunately, with the limited number of articles and the variety of participant populations, we are unable to make conclusions about the effectiveness of ECG-only BP monitoring. We provide 13 recommendations for future ECG-only BP monitoring studies and highlight the limited findings in pregnant and pediatric populations. With the advent of convenient and portable ECG signal recording in smart devices and wearables such as watches, understanding how to apply ECG-only findings to identify hypertension early is crucial to improving health outcomes worldwide.

Differences in Epidemiology and Risk Factors for Atrial Fibrillation Between Women and Men

Atrial fibrillation (AF), the most common sustained cardiac arrhythmia, is one of the most frequent cardiovascular diseases among both women and men. Although age-adjusted AF incidence and prevalence is larger among men, women are older at the time of AF diagnosis and have larger risk for AF-associated adverse outcomes such as morality and stroke. Based on evidence from epidemiological studies, elevated body mass index seems to confer a higher risk of AF among men. However, evidence regarding sex differences in the association between diabetes mellitus, elevated blood pressure, and dysglycemia with AF remains conflicting. While men with AF have larger burden of coronary artery disease, women with AF tend to have a larger prevalence of heart failure and valvular heart disease. Recently, several women-specific risk factors including pregnancy and its complications and number of children have been associated with AF. Earlier age at menopause, despite being a strong marker of adverse cardiometabolic risk, does not seem to be associated with increased risk of AF. To reduce the AF burden in both genders, better understanding of the differences between women and men with regard to AF is central. Large-scale studies are needed to separately investigate and report on women and men. Besides observations from epidemiological and clinical studies, to improve our understanding of sexual dimorphism in AF, sufficiently large genome-wide association studies as well as well-powered Mendelian randomization studies are essential to shed light on the sex-specific nature of the associations of risk factors with AF.

P-wave and QT dispersion in hypertensive disorders of pregnancy

Aim: To compare P-wave and QT dispersion values in hypertensive disorders of pregnancy and controls and also in preeclampsia, chronic hypertension, and gestational hypertension separately.Material and methods: We included 140 hypertensive pregnants and 110 healthy age-matched pregnants in this study. The hypertensive pregnants were divided into three subgroups: preeclampsia (n = 43), chronic hypertension (n = 51), and gestational hypertension (n = 46). P-wave and QT dispersion values were compared between groups.Results: Hypertensive pregnants had higher P-wave (41.74 ± 5.51 vs. 37.73 ± 5.62, p < .001) and QTc dispersion (45.44 ± 7.62 vs. 39.77 ± 8.34, p < .001) values. In subgroup analysis, P-wave dispersion and QTc dispersion were different between preeclamptic, chronic hypertensive, and gestational hypertensive patients. Also, they were significantly higher in chronic hypertension as compared to gestational hypertension and they were higher in preeclampsia than in gestational hypertension. No difference was found according to these parameters between preeclampsia and chronic hypertension. In correlation analysis, both P-wave dispersion and QTc dispersion were positively correlated with systolic (r = 0.409, p < .001 and r = 0.306, p < .001) and diastolic blood pressure (r = 0.390, p < .001 and r = 0.287, p < .001) which are main clinical determinants of hypertensive disorders.Conclusion: In clinical practice, chronic hypertensive pregnants are generally followed up in their future life for cardiovascular disorders. Also, we recommend that we must inform and follow preeclamptic patients for future cardiovascular diseases.

Review article: Investigations and the pregnant woman in the emergency department - part 2: Point-of-care ultrasound, electrocardiography, respiratory function tests and radiology

Accurate assessment of the pregnant patient in the ED depends on knowledge of physiological changes in pregnancy, and how these changes may impact on pathology tests, appearance on point-of-care ultrasound, electrocardiography and respiratory function tests. In addition, the emergency physician needs to be cognisant of disorders that are unique to or more common during pregnancy. Part 2 of this review addresses the role of point-of-care ultrasound in pregnancy, physiological changes that may affect interpretation of point-of-care ultrasound, changes in electrocardiography and respiratory function tests, and the safety of radiological procedures in the pregnant patient. Part 1 addressed potential deviations in laboratory investigation reference intervals resulting from physiological alterations in pregnancy and the important causes of abnormal laboratory results in pregnancy.

Atrial fibrillation in pregnancy: a growing challenge

BACKGROUND

Atrial fibrillation (AF) constitutes a relatively infrequent pregnancy complication, which may be a therapeutic Gordian knot. Indeed, sparse data exist regarding the prevalence, prognosis, and management of AF during pregnancy. In general, AF occurs as a benign, self-limited arrhythmia, but occasionally may have severe hemodynamic consequences in pregnant patients suffering from heart failure, congenital heart disease, or other comorbidities. Extra-cardiac causes of AF should always be meticulously excluded.

REVIEW

Treatment decisions are difficult, since medications may cross the placental barrier and potentially affect fetal growth and organogenesis, or even result in fetal bradyarrhythmias. Treatment goals are not differentiated in comparison to those regarding AF occurring in the general population. Still, while maternal treatment is prioritized, issues regarding fetal health must deliberately be considered. Consequently, hemodynamic instability is to be promptly treated with synchronized electrical cardioversion. In contrast, in stable patients, pharmacologic cardioversion, under appropriate antithrombotic regimen, should be attempted. Selection of appropriate antithrombotic therapy, including novel oral anticoagulants, imposes further difficulties on therapeutic decision-making. Further clinical trials are warranted in order to assess the pathophysiology and prognosis of AF in pregnancy and ameliorate the evidence-based therapeutic strategy in this specific group of the population.

P-wave dispersion: an update

P-wave dispersion (PWD, Pd or Pdis) is a noninvasive electrocardiographic (ECG) marker for atrial remodeling and predictor for atrial fibrillation (AF). PWD is defined as the difference between the widest and the narrowest P-wave duration recorded from the 12 ECG leads. Increased P-wave duration and PWD reflect prolongation of intraatrial and interatrial conduction time with lack of a well-coordinated conduction system within the atrial muscles, with inhomogeneous, asynchronic, pro-inflammatory and anti-inflammatory effect mediated by interleukin-6 (IL-6) in patients with the CG + GG genotype IL-6 -634C/G polymorphism [1] and discontinuous propagation of sinus impulses mainly between the left and right atria, interstitial/extracellular fibroblast activation and collagen deposition with fibrosis (via TGF-β) in atrial tissue, insufficient blood supply, significant not isotropic myoelectric activity, and thin wall thickness and consequent expansion tendency all well-known electrophysiological characteristics in patients with atrial arrhythmias and especially paroxysmal atrial fibrillation (PAF) [2].

Novel indexes of arrhythmogenesis in preeclampsia: QT dispersion, Tp-e interval, and Tp-e/QT ratio

OBJECTIVE

There is increasing evidence that preeclampsia (PE) may also be a risk factor for future cardiovascular diseases (CVDs), including arrhythmia. In this study we aimed to evaluate the association between PE and ventricular repolarization using novel electrocardiogram markers: QT interval duration, Tp-e interval, and Tp-e/QT ratio.

MATERIALS AND METHODS

In this controlled cross-sectional study sixty-four pregnant women with PE (31 with mild and 33 with severe disease) and 32 healthy women with uncomplicated pregnancies in the third trimester were compared by measuring QT parameters, Tp-e interval, and Tp-e/QT ratio.

RESULTS

Tp-e interval and Tp-e/QT ratio values were significantly higher in both the mild and severe PE groups compared to the healthy pregnant group.

CONCLUSION

Prevention of CVD requires that patients be aware of their risk factors, be educated about their risk, and perhaps most importantly perceive them to be at risk. In this study, we documented that PE has a significant effect on ventricular repolarization. This alteration could, in part, explain the increased cardiovascular risk in women with a history of PE. This important association can be used to screen women for increased risk in order to better target counseling regarding lifestyle modifications and to follow up and manage women with a history of hypertensive disease of pregnancy more closely.

Reduced Heart Rate Variability and Altered Cardiac Conduction after Pre-Eclampsia

Pre-eclampsia is a hypertensive disorder of pregnancy that is associated with elevated maternal risk for cardiovascular disease. The aims of this study were to determine the effect of normal pregnancy on postpartum parameters of the electrocardiogram, and furthermore to determine how a history of pre-eclampsia may affect these parameters. Ten-minute high-resolution (1000 Hz) orthogonal Holter electrocardiogram (ECG) recordings were used to measure heart rate variability (HRV). Signal-averaged P-wave and QRS complex durations were determined. Participants included non-pregnant controls, normotensive parous controls and women with a recent history of PE. While reductions in HRV induced by uncomplicated pregnancy returned to non-pregnant levels by 6–8 months postpartum HRV remained reduced in women with a history of PE compared to control groups. In addition, P-Wave and QRS complex durations were prolonged in PE subjects at 6–8 months postpartum compared to control groups. Only QRS duration was independent of differences in blood pressure. These results suggest increased sympathetic cardiac activity, and delayed myocardial conduction in women after PE; alterations consistent with cardiac remodeling and increased risk for arrhythmia. In examining the association between PE and cardiovascular disease, identification of ECG abnormalities soon after pregnancy in women with a history of PE highlights a unique opportunity for early identification and screening in this population before other risk factors become apparent.

Electrocardiographic P-Wave Duration, QT Interval, T Peak to End Interval and Tp-e/QT Ratio in Pregnancy with Respect to Trimesters

BACKGROUND

P-wave duration helps to determine the risk of atrial arrhythmia, especially atrial fibrillation. QT interval, T peak to end interval (Tp-e), and Tp-e/QT ratio are electrocardiographic indices related to ventricular repolarization which are used to determine the risk of ventricular arrhythmias. We search for any alterations in electrocardiographic indices of arrhythmia in the pregnancy period with respect to trimesters.

METHODS

We enrolled 154 pregnant and 62 nonpregnant, healthy women into this cross-sectional study. Maximum and minimum P-wave durations (Pmax, Pmin), and QT intervals (QTmax, QTmin) were measured from 12 leads. QT measurements were corrected using Fridericia (QTc-Fr) and Bazett's (QTc-Bz) correction. Tp-e interval was obtained from the difference between QT interval, and QT peak interval (QTp) measured from the beginning of the QRS until the peak of the T wave. Tp-e/QT ratio was calculated using these measurements.

RESULTS

Pmax were 93.0 ± 9.1, 93.9 ± 8.9, 97.9 ± 5.6, 99.0 ± 6.1 in nonpregnant women, first, second, third trimesters of pregnancy, respectively (P = 0.001); whereas Pmin values were not significantly different. QTc-Fr max were 407.4 ± 14.2, 408.5 ± 16.1, 410.1 ± 13.1, 415.1 ± 10.1 (P = 0.007); Tp-e were 72.7 ± 6.2, 73.2 ± 6.5, 77.2 ± 8.9, 87.2 ± 9.6 (P < 0.001); and Tp-e/QT were 0.17 (0.14-0.20), 0.17 (0.14-0.20), 0.18 (0.15-0.23), 0.20 (0.16-0.25) in nonpregnant women, first, second, and third trimesters of pregnancy respectively (P < 0.001). None of the participants experienced any arrhythmic event.

CONCLUSIONS

P-wave duration is prolonged in the second trimester, and resumes a plateau thereafter. Maximum QTc interval, Tp-e interval and Tp-e/QT ratio are increased in the late pregnancy. Although these indices are altered during the course of pregnancy, they all remain in the normal ranges.