Arrhythmogenic Pregnancy as a Systems-Level Phenotype: A Systematic Review of the Interplay Between Structural Heart Disease, Hypertensive Disorders, and Electrophysiologic Remodeling

Pregnancy is often described as a physiological stress test for the cardiovascular system, yet the possibility that it may function as a transiently arrhythmogenic state has not been examined in an integrated way. This review was undertaken to synthesize current evidence on how structural heart disease, hypertensive disorders of pregnancy, and electrophysiologic remodeling intersect during gestation and the postpartum period. A systematic search of PubMed/MEDLINE, Embase, Scopus, Web of Science, and Cochrane Library, supplemented by registry and reference screening, identified 1,380 records, of which 43 studies met predefined inclusion criteria after PRISMA-guided selection. What becomes apparent—though not always explicitly stated in individual reports—is that these domains do not act in isolation. Hemodynamic loading, endocrine signaling, vascular dysfunction, and inflammatory activation appear to converge on a shared myocardial substrate, subtly altering conduction properties and repolarization dynamics. In clinical terms, this convergence helps explain why arrhythmias range from relatively benign supraventricular tachycardia to more consequential atrial fibrillation or ventricular arrhythmias, particularly in the presence of hypertensive or structural pathology. There is, however, a lingering ambiguity: whether these changes resolve completely after delivery or leave a residual electrophysiologic imprint remains uncertain. Taken together, the findings suggest that pregnancy should be reconsidered not simply as a trigger in susceptible individuals, but as a systems-level condition capable of generating arrhythmogenic vulnerability. This reframing carries implications for surveillance, especially in the early postpartum period, and points toward the need for longitudinal, mechanism-informed research that bridges obstetrics and cardiovascular medicine.