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BACKGROUND: Fetal alcohol spectrum disorders (FASDs) impact up to 5% of U.S. school age children; however, the burden of congenital and acquired cardiovascular disease (CVD) in adults with FASDs remains poorly defined. We investigated associations between FASDs, cardiometabolic abnormalities, and CVD using electronic health record (EHR) data.METHODS: We performed a retrospective cohort study of adults (≥18 years) receiving ambulatory care with a FASD diagnosis ( = 208, mean age 38.4±14.5, 50% female) and age- and sex-matched control patients without FASD ( = 824, mean age 41.6±14.5, 50% female). Cardiometabolic outcomes were overweight/obesity, dyslipidemia, and diabetes mellitus. Cardiovascular outcomes were congenital heart defects (CHDs), heart murmur, hypertension, conduction defects, arrhythmias, structural heart remodeling, systolic and diastolic dysfunction, heart failure, myocardial infarction (MI), stroke, and thromboembolic events. Associations were assessed using age-adjusted logistic and Poisson regression, with sex-by-diagnosis interaction testing. Multivariable logistic regression was then used to estimate the odds of cardiovascular outcomes with additional adjustment for cardiometabolic conditions. Associations between CHD and CVD outcomes were evaluated using Fisher's exact tests.RESULTS: Adults with FASDs had a higher prevalence (p<0.05) of cardiometabolic abnormalities, including dyslipidemia, type 2 diabetes, and the co-occurrence of multiple cardiometabolic abnormalities (overweight/obese, HDL cholesterol < 40 mg/dL, and type 2 diabetes mellitus). Overweight/obesity was more prevalent in females with FASDs but not males. CHDs were significantly more common in individuals with FASDs than controls (6% vs 1%, p < 0.001). Compared with controls, the FASD cohort had a higher incidence of systolic and diastolic dysfunction (6% vs. 2%), structural heart remodeling (11% vs 5%), MI (6% vs. 2%), stroke (4% vs 1%), and thromboembolic events (4% vs 1%; all p < 0.05). Significant sex-by-diagnosis interactions were observed for hypertension, arrhythmia, and heart failure, with elevated rates specific to FASD females. In individuals with FASDs, CHD diagnosis was associated with an increased incidence of conduction defects, arrhythmias, heart remodeling, heart failure, and systolic and diastolic dysfunction. Increased CVD burden in FASD adults remained significant after adjustment for BMI, composite cardiometabolic abnormalities, and hyperlipidemia.CONCLUSIONS: Adults with FASDs exhibit an increased burden of CVD not fully explained by conventional cardiometabolic risk factors. These findings support enhanced cardiovascular screening in individuals with FASDs.