Premature birth and long-term risk of heart failure
Myron Yaster MD
Casey Crump, Alan Groves, Jan Sundquist, Kristina Sundquist. Association of Preterm Birth With Long-term Risk of Heart Failure Into Adulthood. JAMA Pediatr. 2021 Jul 1;175(7):689-697. PMID: 33818601
Mandy Brown Belfort, Suzanne Brown Sacks. Preterm Birth and Heart Failure in Infancy and Beyond: Born With a Broken Heart? JAMA Pediatr 2021 Jul 1;175(7):673-675. PMID: 33818589
We’ve all been there. You are evaluating or treating a “train wreck”, former (fill in the blank…premie, ICU, trauma, oncology…) patient presenting for the umpteenth time…and in your heart of hearts you wonder “was it worth it”? My (and Ron Littman’s) legendary mentors, Drs. Jack Downes and Russ Raphaely, of the Children’s Hospital of Philadelphia, would always say: “if you can’t accept the failures, you can’t accept the successes”. Which brings me to this eye-popping article and editorial on the association of prematurity and long-term heart failure. If you have a moment, at least read the editorial…it’s worth the time and effort.
Belfort and Sacks write: “The past 30 years have seen major advances in the medical care of preterm neonates such that currently more than 95% of the approximately 400 000 preterm infants born each year in the US survive to discharge from the neonatal intensive care unit (NICU). For even the smallest and least mature infants (extremely preterm infants born <28 weeks’ gestation), survival is approximately 90%. Given these successes, the focus must now shift from reducing mortality to improving long-term health outcomes in this vulnerable population”.
Most of us are aware of the risk of neurologic injury in premie graduates. What is less known, at least to me, is the high risk of “hypertension, type-2 diabetes, lipid disorders, sleep disordered breathing, chronic kidney disease, “cardiometabolic” disorders, circulatory anomalies, and cardiac remodeling”, all of which are known risk factors for heart failure (HF). Are former premies therefore at greater risk of HF throughout their lives? The unequivocal answer in this study is “YES”!
In a population wide study that included more than 4 million participants observed throughout more than 40 years, in today’s PAAD, Crump et al. found that “preterm birth at less than 37 weeks’ gestation was associated with a 2.7-fold increased incidence of heart failure compared with full-term (age 39-41 weeks) birth. Stratified analyses revealed several clinically relevant results. First, the risk of heart failure was increased not just for heart failure during infancy (age <1 year, 4.5-fold increased risk) and childhood (age 1-17 years, 3.4-fold increased risk), but also for heart failure that presented during adulthood (age 18-43 years, 1.4-fold increased risk). Second, the risk of developing heart failure at all ages was substantially higher for the least mature infants. For example, the adult-onset heart failure risk for extremely preterm infants was 4.7-fold higher than for full term-born infants, whereas the risk for late-preterm infants (34-36 weeks) was 1.2-fold higher than for full-term infants”. Further, these risks “persisted even after excluding individuals with congenital anomalies”. Finally, “cardiac imaging studies in young adults have found evidence of cardiac remodeling in those who were born preterm, including increased left ventricular mass; reduced diastolic myocardial relaxation, right ventricular function, and stroke volume; and decreased myocardial functional reserve during physiologic stress”.
Wow! Perhaps, I shouldn’t have been surprised! It really does make intuitive sense that the incidence of HF in premie graduates is higher than in the rest of the population…and thank goodness for the Swedes! I don’t think this study could have ever been done in the U.S. Could you imagine, even for a minute, obtaining universal health records over a 40-year period? Perhaps in Olmsted County home of the Mayo Clinic, but the entire U.S.? I think going forward we will need to figure out methods of HF risk reduction in our premie graduates and not limit our interventions to neurodevelopment issues.
Myron Yaster MD