Early Mortality, Cardiovascular, and Renal Diseases in Women's Lives Following Hypertensive Disorders of Pregnancy: The Prospective Nationwide Study CONCEPTION

BACKGROUND

We aimed to evaluate the impact of hypertensive disorders of pregnancy occurrence, recurrence, onset time, and severity on mortality and on a wide range of cardiovascular outcomes in France.

METHODS AND RESULTS

CONCEPTION (Cohort of Cardiovascular Diseases in Pregnancy) is a French nationwide prospective cohort using data from the National Health Data System. We included all women in CONCEPTION with no history of a cardiovascular event who delivered in France for the first time between 2010 and 2018 (N=2 819 655). Hypertensive disorders of pregnancy and cardiovascular outcomes during the study follow-up were identified using algorithms combining International Classification of Diseases, Tenth Revision (ICD-10) coded diagnoses during hospitalization and purchases of medication between 2010 and 2021. We fitted Cox models with time-varying exposure to assess the associations of hypertensive disorders of pregnancy with mortality and cardiovascular events. Women with gestational hypertension had a 1.25- to 2-fold higher risk of stroke, acute coronary syndrome, peripheral arterial disease, pulmonary embolism, and chronic kidney disease, and a 2- to 4-fold higher risk of rhythm and conduction disorder and heart failure. Women with preeclampsia had a 1.35- to 2-fold higher risk of rhythm or conduction disorder and pulmonary embolism during follow-up; a 2- to 4-fold higher risk of stroke, acute coronary syndrome, and peripheral arterial disease; and a 7- to 9-fold higher risk of heart failure and chronic kidney disease. They were 1.8 times more likely to die and 4.4 times more likely to die of cardiovascular causes.

CONCLUSIONS

Hypertensive disorders of pregnancy drastically increase the risk of mortality, cardiovascular, and renal events early after pregnancy. Recurrent, severe, and early-onset preeclampsia further increases this risk.

Aspirin for the Prevention of Early and Severe Pre-Eclampsia Recurrence: A Real-World Population-Based Study

BACKGROUND

Many clinical trials have reported that low-dose aspirin decreases the risk of pre-eclampsia in women with prior pre-eclampsia. However, its impact in a real-world population has not been fully assessed.

OBJECTIVES

To assess the rates of low-dose aspirin initiation during pregnancy in women with a history of pre-eclampsia, and to evaluate the impact of low-dose aspirin in prevention of pre-eclampsia recurrence in a real-world population.

STUDY DESIGN

CONCEPTION is a French nationwide cohort study which uses data from the country's National Health Data System database. We included all women in France who gave birth at least twice between 2010-2018, and who had pre-eclampsia during their first pregnancy. Every dispensing of low-dose aspirin (75-300 mg) between the beginning of their second pregnancy and 36 weeks of gestation (WG) was identified. We used Poisson regression models to estimate the adjusted incidence rate ratios (aIRRs) of receiving aspirin at least once during their second pregnancy. In women who had early and/or severe pre-eclampsia during their first pregnancy, we estimated the IRRs of pre-eclampsia recurrence during their second pregnancy according to the aspirin therapy.

RESULTS

In 28,467 women who were included in the study, the aspirin initiation rate during the second pregnancy ranged from 27.8% for women in whose first pregnancy the pre-eclampsia was mild and late, to 79.9% for those women whose pre-eclampsia was severe and early. Just over half (54.3%) of those treated with aspirin-initiated treatment before 16 WG and adhered to treatment. Compared with women with mild and late pre-eclampsia, the aIRRs (95% CI) for receiving aspirin at least once during the second pregnancy were 1.94 (1.86-2.03) for women with severe and late pre-eclampsia, 2.34 (2.17-2.52) for those with early and mild pre-eclampsia, and 2.87 [2.74-3.01] for those with early and severe pre-eclampsia E. Social deprivation was associated with a lower initiation of aspirin (IRR = 0.74 [0.70-0.78]). Aspirin was not associated with a lower risk of mild and late pre-eclampsia, severe and late pre-eclampsia, or mild and early pre-eclampsia during the second pregnancy. The aIRRs for severe and early pre-eclampsia during the second pregnancy were 0.77 (0.62-0.95) for women who received prescribed aspirin at least once, 0.71 (0.5-0.89) for those who initiated aspirin therapy before 16 WG, and 0.60 (0.47-0.77) for those who adhered to aspirin treatment throughout their second pregnancy. The risk of severe and early pre-eclampsia was lower only when the prescribed mean daily dose was ≥ 100 mg/day.

CONCLUSION

In women with a history of pre-eclampsia, aspirin initiation during a second pregnancy and adherence to the prescribed dosage were largely insufficient, especially for women experiencing social deprivation. Aspirin initiated before 16 WG at a dose ≥ 100 mg/day was associated with a lower risk of severe and early pre-eclampsia.

P3345Stroke and death in atrial fibrillation patients newly treated by oral anticoagulants in France: a national cohort study 2012–2016

Background

Introduction of new oral anticoagulants (OAC) lead to an increase in atrial fibrillation (AF) patients treated with those drugs. Few epidemiological data on outcomes are available in France or abroad in this population. There is an important need to follow up patients newly diagnosed for AF and treated by OAC, and estimate stroke and mortality outcomes at national level in unselected patients' population. The French “Système national des données de santé” (SNDS) gathered enough medical information on the overall French population, with complete follow-up until patient's death.

Purpose

The objective of this study was to analyze stroke and death outcomes and their determinants in a cohort of AF patients newly treated by OAC in France between 2012 and 2016.

Methods

All AF patients aged over 20 years old, residing in France, and newly treated by OAC between 2012 and 2016 were included in a cohort. The date of OAC delivery was considered as the inclusion date. Patients were followed till 31 of December 2017. Main outcomes studied were the first hospitalisation for stroke or death. We used a Fine and Gray regression model to estimate subdistribution hazard ratio (SHR) for stroke. Cox regression models were used to compute cause-specific hazard ratios (CSHR) for stroke and death respectively. Analyses were adjusted for main confounders.

Results

The total number of patients enrolled in the study for the period 2012–2016 was 662,298. Mean age at inclusion was 74.9 years old. Women accounted for 47.8% of the study population. Globally, 3.8% of patients experienced stroke after initiation of OAC and 13.9% of patients died over the study period with 1.1% of death occurring after a stroke. The median follow-up for stroke or death events was 1094 days, 1208 days for stroke and 1123 days for death. Incidence rates of stroke or death reached 53.3 [53.0–53.6] per 1,000 person-year and, 11.3 [11.2–11.5] and 44.0 [43.7–44.3] for stroke and death respectively. Advanced age, history of stroke, acute coronary syndrome (ACS), chronic kidney disease (CKD), treated hypertension, diabetes and to be included during the first year of the study period were associated with an increase in the subdistribution hazard of stroke. Significant differences were found by age group such as an increase in SHR for stroke in women aged over 85 years compared to men of the same age. Cause-specific analyzes gave similar results for stroke. History of heart failure, ACS, CKD, hemorrhages, treated hypertension and diabetes were associated with increased hazard of death. On the contrary, female sex was associated with a significant decrease in the hazard of death only.

Conclusion

Stroke incidence and mortality rate in AF patients newly treated by OAC were high. Several factors were associated with increased hazard of stroke and death but differed according to patient's age.