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RESEARCH: Raluca Ionescu-Ittu, Ariane J Marelli, Andrew S Mackie, and Louise Pilote Prevalence of severe congenital heart disease after folic acid fortification of grain products: time trend analysis in Quebec, Canada BMJ 2009; 338: b1673 [Abstract] [Full text]

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Decline in prevalence of severe Congenital Heart Disease

Maria Loane, Helen Dolk , Maria Loane, Ester Garne, Lenore Abramsky , Hermien de Walle and a EUROCAT Working Group.   (6 August 2009)

Decline in prevalence of severe Congenital Heart Disease 6 August 2009
Maria Loane, Lecturer University of Ulster BT370QB, Helen Dolk , Maria Loane, Ester Garne, Lenore Abramsky , Hermien de Walle and a EUROCAT Working Group. Send response to journal: Re: Decline in prevalence of severe Congenital Heart Disease	We were interested to read Ionescu-Ittu et al’s (1), Gardiner and Fouron (2) and Prsa et al’s (3) interpretation of a decline in prevalence of severe congenital heart disease in Quebec since 1998 following folic acid fortification. We examined EUROCAT data on severe CHD from 1990 to 2006 (see Figure), which include terminations of pregnancy for fetal anomaly as well as livebirths, and fetal deaths from 20 weeks gestation. These data are based on 14 population-based registries* in 11 countries of Europe covering a population of 3,614,371 births 1990-2006, all of whom contributed to a recent report on CHD prevalence in Europe for the period 2000-2005 (4). We see a rise in prevalence from 1990 to 2000, followed by a decline. The prevalence of terminations of pregnancy for CHD rose until 2000 and then stabilised. The decline since 1998 including all cases is statistically significant (p<0.001). In Europe there is no mandatory fortification of food with folic acid. Policies regarding folic acid supplementation have not been successful at reaching the majority of women preconceptionally in most countries, and therefore have not led to a significant overall decline in neural tube defects (5,6). It is possible that starting supplementation early in pregnancy is more successful at preventing CHD with a slightly later critical period of development than neural tube defects. Nevertheless the pattern of CHD prevalence since 1990 does not suggest a relationship with folic acid supplementation. We therefore believe alternative interpretations of this decline need to be considered. Detailed information on CHD prevalence in 20 European countries is available at EUROCAT’s website (7). *14 registries: Hainaut, Antwerp (Belgium); Zagreb (Croatia); Odense (Denmark); Paris (France); Saxony-Anhalt, Mainz (Germany); Dublin (Ireland); Tuscany, Emilia Romagna (Italy); Malta; Northern Netherlands; Basque Country (Spain); Vaud (Switzerland); References 1. Ionescu-Ittu R, Marelli AJ, Mackie AS and Pilote L. Prevalence of severe congenital heart disease after folic acid fortification of grain products: time trend analysis in Quebec, Canada. BMJ 2009; 338; b1673 2. Gardiner HM, Fouron J-C. Folic acid fortification and congenital heart disease. BMJ 2009; 338:1221-2. 3. Prsa M, Saroli T, Mackie AS, Dancea AD, Correa JA, Asgharian M. Birth Prevalence of Congenital Heart Disease. Epidemiology 2009; 20:466-468. 4. EUROCAT Special Report: Congenital Heart Defects in Europe, 2000-2005. 2009. http://www.eurocat.ulster.ac.uk/pdf/ML/Reports/EUROCAT-Special- Report-CHD.pdf 5. EUROCAT Special Report on Prevention of Neural Tube Defects by Periconceptional Folic Acid Supplementation in Europe 2005. http://www.eurocat.ulster.ac.uk/pubdata/Folic-Acid.html#December%202005 6. Busby A, Abramsky L, Dolk H, Armstrong B and a EUROCAT Folic Acid Working Group. Preventing Neural Tube Defects in Europe: Population Based Study. British Medical Journal. 2005; Vol 330, pp 574-575. 7.EUROCAT website prevalence tables 1980-2007 http://www.eurocat.ulster.ac.uk/pubdata/tables.html LB=livebirths, FD=fetal deaths, TOPFA= terminations of pregnancy following prenatal diagnosis. Competing interests: None declared