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Wang X, Chen L, Wei J, Zheng H, Zhou N, Xu X, Deng X, Liu T, Zou Y. The immune system in cardiovascular diseases: from basic mechanisms to therapeutic implications. Signal Transduct Target Ther 2025; 10:166. [PMID: 40404619 PMCID: PMC12098830 DOI: 10.1038/s41392-025-02220-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2024] [Revised: 12/22/2024] [Accepted: 03/20/2025] [Indexed: 05/24/2025] Open
Abstract
Immune system plays a crucial role in the physiological and pathological regulation of the cardiovascular system. The exploration history and milestones of immune system in cardiovascular diseases (CVDs) have evolved from the initial discovery of chronic inflammation in atherosclerosis to large-scale clinical studies confirming the importance of anti-inflammatory therapy in treating CVDs. This progress has been facilitated by advancements in various technological approaches, including multi-omics analysis (single-cell sequencing, spatial transcriptome et al.) and significant improvements in immunotherapy techniques such as chimeric antigen receptor (CAR)-T cell therapy. Both innate and adaptive immunity holds a pivotal role in CVDs, involving Toll-like receptor (TLR) signaling pathway, nucleotide-binding oligomerization domain-containing proteins 1 and 2 (NOD1/2) signaling pathway, inflammasome signaling pathway, RNA and DNA sensing signaling pathway, as well as antibody-mediated and complement-dependent systems. Meanwhile, immune responses are simultaneously regulated by multi-level regulations in CVDs, including epigenetics (DNA, RNA, protein) and other key signaling pathways in CVDs, interactions among immune cells, and interactions between immune and cardiac or vascular cells. Remarkably, based on the progress in basic research on immune responses in the cardiovascular system, significant advancements have also been made in pre-clinical and clinical studies of immunotherapy. This review provides an overview of the role of immune system in the cardiovascular system, providing in-depth insights into the physiological and pathological regulation of immune responses in various CVDs, highlighting the impact of multi-level regulation of immune responses in CVDs. Finally, we also discuss pre-clinical and clinical strategies targeting the immune system and translational implications in CVDs.
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Affiliation(s)
- Xiaoyan Wang
- Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital and Institutes of Biomedical Sciences, Fudan University, Shanghai, China.
- State Key Laboratory of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China.
| | - Liming Chen
- Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital and Institutes of Biomedical Sciences, Fudan University, Shanghai, China
- State Key Laboratory of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jianming Wei
- Central Diagnostics Laboratory, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Hao Zheng
- Jiangsu Provincial Key Laboratory of Critical Care Medicine and Department of Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, China
| | - Ning Zhou
- Department of Cardiovascular Medicine, Anzhen Hospital Affiliated to Capital Medical University, Beijing, China
| | - Xinjie Xu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xin Deng
- Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital and Institutes of Biomedical Sciences, Fudan University, Shanghai, China
- State Key Laboratory of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Tao Liu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine and Department of Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, China.
- Department of Biochemistry and Molecular Biology, School of Medicine, Southeast University, Jiangsu, Nanjing, China.
- State Key Laboratory of Respiratory Disease, Joint International Research Laboratory of Respiratory Health, National Clinical Research Center for Respiratory Disease, National Center for Respiratory Medicine, Department of Allergy and Clinical Immunology, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China.
| | - Yunzeng Zou
- Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital and Institutes of Biomedical Sciences, Fudan University, Shanghai, China.
- State Key Laboratory of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China.
- Institutes of Advanced Medical Sciences and Huaihe Hospital, Henan University, Kaifeng, Henan, China.
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Ilić A, Tadić S, Stefanović M, Ilić D, Petrović M, Milovančev A, Bjelobrk M, Miljković T, Dabović D, Stojšić S, Bačevac M, Stojšić-Milosavljević A. Impact of Three-Dimensional Assessment of Maternal Left Ventricular Systolic Function on Pregnancy Outcomes. Rev Cardiovasc Med 2025; 26:27639. [PMID: 40351686 PMCID: PMC12059735 DOI: 10.31083/rcm27639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2024] [Revised: 01/09/2025] [Accepted: 01/24/2025] [Indexed: 05/14/2025] Open
Abstract
Background Hypertensive disorders in pregnancy (HDP) are associated with adverse pregnancy outcomes. Three-dimensional (3D) echocardiography provides greater accuracy for assessing cardiac geometry and function during pregnancy. The aim was to assess the impact of the 3D left ventricle (LV) systolic function in HDP on pregnancy outcomes. Methods The prospective cohort study included primiparous with singleton pregnancies, without previous comorbidities who underwent medical history assessment, laboratory tests, ambulatory blood pressure monitoring (ABPM), and transthoracic echocardiography at baseline and six weeks after delivery. Participants were divided into a HDP group and a control group. Pregnancy outcomes (intrauterine growth restriction (IUGR), preterm delivery, and birth weight) were recorded and analyzed. Results The study involved 174 HDPs and 64 controls, with a median gestational age of 34 weeks (31; 36). Compared to controls HDP exhibited significantly impaired values in both two-dimensional (2D) and 3D parameters for the systolic and diastolic function of the LV. They had higher LV mass index values and lower absolute values for 2D global longitudinal strain and 3D LV strain in all directions (p < 0.001). Multivariable regression analysis revealed that body mass index (BMI) with odds ratio (OR) of 0.751 (95% confidence interval (CI): 0.666-0.847, p < 0.001) and 3D LV global area strain (GAS) with OR of 0.234 (95% CI: 0.155-0.352, p < 0.001) were the strongest predictors of IUGR, while BMI with OR of 0.832 (95% CI: 0.758-0.914), nighttime systolic blood pressure (SBP) with OR of 1.055 (95% CI: 1.032-1.079, p < 0.01) and 3D LV ejection fraction (EF) with OR of 0.780 (95% CI: 0.687-0.885) were the strongest predictors of preterm delivery. The receiver operating characteristic (ROC) curve showed that the model with BMI and 3D LV GAS can be a good predictor for IUGR with an area under the curve (AUC) 0.951 (0.925-0.976) with 89.5% sensitivity and 86.4% specificity, p < 0.001, while the model with BMI, nighttime SBP and 3D LV EF is a predictor for preterm delivery with AUC of 0.835 (0.776-0.893) with 79.1% sensitivity and 73.7% specificity, p < 0.001. Person correlation showed a significant positive correlation between birth weight and 3D GAS, r = 0.485; p < 0.001. Conclusions LV GAS is significantly associated with IUGR and birth weight, while 3D LV EF strongly predicts preterm delivery.
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Affiliation(s)
- Aleksandra Ilić
- Faculty of Medicine, University of Novi Sad, 21000 Novi Sad, Serbia
- Institute of Cardiovascular Diseases of Vojvodina, 21208 Sremska Kamenica, Serbia
| | - Snežana Tadić
- Faculty of Medicine, University of Novi Sad, 21000 Novi Sad, Serbia
- Institute of Cardiovascular Diseases of Vojvodina, 21208 Sremska Kamenica, Serbia
| | - Maja Stefanović
- Faculty of Medicine, University of Novi Sad, 21000 Novi Sad, Serbia
- Institute of Cardiovascular Diseases of Vojvodina, 21208 Sremska Kamenica, Serbia
| | - Djordje Ilić
- Faculty of Medicine, University of Novi Sad, 21000 Novi Sad, Serbia
- Department of Obstetrics and Gynecology, Clinical Center of Vojvodina, 21000 Novi Sad, Serbia
| | - Milovan Petrović
- Faculty of Medicine, University of Novi Sad, 21000 Novi Sad, Serbia
- Institute of Cardiovascular Diseases of Vojvodina, 21208 Sremska Kamenica, Serbia
| | - Aleksandra Milovančev
- Faculty of Medicine, University of Novi Sad, 21000 Novi Sad, Serbia
- Institute of Cardiovascular Diseases of Vojvodina, 21208 Sremska Kamenica, Serbia
| | - Marija Bjelobrk
- Faculty of Medicine, University of Novi Sad, 21000 Novi Sad, Serbia
- Institute of Cardiovascular Diseases of Vojvodina, 21208 Sremska Kamenica, Serbia
| | - Tatjana Miljković
- Faculty of Medicine, University of Novi Sad, 21000 Novi Sad, Serbia
- Institute of Cardiovascular Diseases of Vojvodina, 21208 Sremska Kamenica, Serbia
| | - Dragana Dabović
- Faculty of Medicine, University of Novi Sad, 21000 Novi Sad, Serbia
- Institute of Cardiovascular Diseases of Vojvodina, 21208 Sremska Kamenica, Serbia
| | - Snežana Stojšić
- Institute of Cardiovascular Diseases of Vojvodina, 21208 Sremska Kamenica, Serbia
| | - Muamer Bačevac
- Department of Internal Medicine, Opšta bolnica Novi Pazar, 36300 Novi Pazar, Serbia
| | - Anastazija Stojšić-Milosavljević
- Faculty of Medicine, University of Novi Sad, 21000 Novi Sad, Serbia
- Institute of Cardiovascular Diseases of Vojvodina, 21208 Sremska Kamenica, Serbia
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Ghossein‐Doha C, Thilaganathan B, Vaught AJ, Briller JE, Roos‐Hesselink JW. Hypertensive pregnancy disorder, an under-recognized women specific risk factor for heart failure? Eur J Heart Fail 2025; 27:459-472. [PMID: 39563186 PMCID: PMC11955315 DOI: 10.1002/ejhf.3520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2024] [Revised: 09/26/2024] [Accepted: 10/24/2024] [Indexed: 11/21/2024] Open
Abstract
During pregnancy, the maternal cardiovascular (CV) system undergoes major haemodynamic alterations ensuring adequate placental perfusion and a healthy pregnancy course. Hypertensive disorders of pregnancy (HDP) occur in almost 10% of gestations and preeclampsia, a more severe form, in 3-4%. Women with HDP demonstrated impaired myocardial function, biventricular chamber dysfunction and adverse biventricular remodelling. Shortly after delivery, women who experienced HDP express increased risk of classic CV risk factors such as hypertension, renal disease, abnormal lipid profile, and diabetes. Within the first two decades following a HDP, women experience increased rates of heart failure, chronic hypertension, ischaemic heart and cerebral disease. The mechanism underlying the relationship between HDP in younger women and CV disease later in life could be explained by sharing pre-pregnancy CV risk factors or due to a direct impact of HDP on the maternal CV system conferring a state of increased susceptibility to future metabolic or haemodynamic insults. Racial disparities in CV risk and social determinants of health also play an important role in their remote CV risk. Although there is general agreement that women who suffered from HDP should undertake early CV screening to allow appropriate prevention and timely treatment, a screening and intervention protocol has not been standardized due to limited available evidence. In this review, we discuss why women with hypertensive pregnancy may be disproportionately affected by heart failure with preserved ejection fraction and how cardiac remodelling during or after pregnancy may influence its development.
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Affiliation(s)
- Chahinda Ghossein‐Doha
- Cardiovascular Institute, Thorax Center, Department of CardiologyErasmus Medical CenterRotterdamThe Netherlands
| | - Basky Thilaganathan
- Molecular and Clinical Sciences Research InstituteSt. George's University of LondonLondonUK
- Fetal Medicine Unit, Department of Obstetrics and GynaecologySt George's University Hospitals NHS Foundation TrustLondonUK
| | - Arthur Jason Vaught
- Department of Gynecology and ObstetricsJohns Hopkins University School of MedicineBaltimoreMDUSA
| | - Joan E. Briller
- Division of Cardiology, Department of Medicine and Department of Obstetrics and GynecologyUniversity of Illinois ChicagoChicagoILUSA
| | - Jolien W. Roos‐Hesselink
- Cardiovascular Institute, Thorax Center, Department of CardiologyErasmus Medical CenterRotterdamThe Netherlands
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Ormesher L, Stewart J, Renwick B, Shawkat E, Myers JE. Is there a relationship between visit-to-visit blood pressure variability and adverse perinatal outcomes? Pregnancy Hypertens 2025; 39:101200. [PMID: 39951841 DOI: 10.1016/j.preghy.2025.101200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Revised: 01/13/2025] [Accepted: 01/29/2025] [Indexed: 02/16/2025]
Abstract
OBJECTIVE To explore the relationship between blood pressure (BP) variability and perinatal outcomes. STUDY DESIGN This was a retrospective study of 996 pregnant women with hypertension/risk factors for hypertension in pregnancy. BP variability was calculated by visit-to-visit standard deviation (SD) and mean difference (MD). Logistic regression explored the relationship between BP variability and perinatal outcome, adjusting for confounders. MAIN OUTCOME MEASURES Correlation between BP variability and i) fetal growth restriction (FGR) and ii) preterm birth (PTB). RESULTS FGR and PTB complicated 128/996 (13 %) and 233/996 (23 %) pregnancies. At visit 1, 61 (6 %) women were taking labetalol, 125 (13 %) were taking calcium channel blockers and 780 (78 %) were not taking antihypertensives. Increased BP variability was associated with FGR and PTB. These relationships persisted after adjustment for number of antihypertensives, pre-pregnancy BP, BMI, ethnicity and previous FGR for systolic but not diastolic BP variability (adjusted OR for FGR: 1.16 [95 % C.I. 1.03-1.30]; PTB: 1.16 [1.05-1.29]). However, statistical significance was lost after adjustment for maximum BP. Nifedipine was associated with increased BP variability, compared with labetalol, despite adjustment for ethnicity and pre-existing hypertension (adjusted difference: 1.93 mmHg [0.13-3.73], p = 0.04). CONCLUSIONS Increased visit-to-visit systolic but not diastolic BP variability is associated with adverse perinatal outcomes. Nevertheless, it is unclear whether BP lability directly influences perinatal outcome, or merely reflects peak BP. The difference in BP variability between antihypertensives may reflect varying effectiveness or factors influencing antihypertensive choice. Prospective research is needed to investigate any potential link between antihypertensive medications, BP variability and perinatal outcome.
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Affiliation(s)
- Laura Ormesher
- Maternal and Fetal Health Research Centre, Division of Developmental Biology and Medicine, The University of Manchester, Manchester M13 9WL, United Kingdom; Saint Mary's Hospital, Manchester University NHS Foundation Trust, Manchester M13 9WL, United Kingdom.
| | - Jill Stewart
- Maternal and Fetal Health Research Centre, Division of Developmental Biology and Medicine, The University of Manchester, Manchester M13 9WL, United Kingdom
| | - Beth Renwick
- Maternal and Fetal Health Research Centre, Division of Developmental Biology and Medicine, The University of Manchester, Manchester M13 9WL, United Kingdom
| | - Emma Shawkat
- Saint Mary's Hospital, Manchester University NHS Foundation Trust, Manchester M13 9WL, United Kingdom
| | - Jenny E Myers
- Maternal and Fetal Health Research Centre, Division of Developmental Biology and Medicine, The University of Manchester, Manchester M13 9WL, United Kingdom; Saint Mary's Hospital, Manchester University NHS Foundation Trust, Manchester M13 9WL, United Kingdom
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Liu J, Dong Y, Zhou Y, Wang W, Li Y, Pei J. Exploring genetic associations between immune cells and hypertensive disorder of pregnancy using Mendelian randomization. BMC Pregnancy Childbirth 2024; 24:756. [PMID: 39548401 PMCID: PMC11566496 DOI: 10.1186/s12884-024-06950-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Accepted: 11/04/2024] [Indexed: 11/18/2024] Open
Abstract
BACKGROUND Observational epidemiological studies suggested that immunological dysregulation and inflammation play a significant role in the placental and renal dysfunction that leads to maternal hypertension. The immunophenotypes' possible causalities with hypertensive disease of pregnancy remain ambiguous. We performed two-sample Mendelian randomization (MR) analyses to comprehensively investigate the causal effect of immunophenotypes on hypertensive disorder of pregnancy (HDP). METHODS The large-scale genome-wide association studies (GWASs) data on immunological traits was taken from public catalog for 731 immunophenotypes. The summarized GWAS data in 4 types of HDP were retrieved from FinnGen database, including 811,605 Finnish individuals. The primary analysis was the inverse variance weighted (IVW) method, supplemented by conducting sensitivity analysis. To confirm whether cardiovascular proteins mediated the causal effect of immune cells on HDP, we additionally executed a mediation MR study. RESULTS After looking into genetically predicted immunophenotype biomarkers, we discovered 14 highly correlative immunophenotypes and 104 suggestive possible factors. The IVW analysis indicated that HLA DR on myeloid DC, HLA DR on plasmacytoid DC, and HLA DR on DC had a significant association with pre-eclampsia/eclampsia (PE), whereas CD4+ CD8dim AC and CD4+ CD8dim % leukocyte were protective against gestational hypertension (GH). All of HDP in our study had no statistically significant impact on immune cells, according to reverse MR analysis. The mediating role of LOX-1between HLA DR on plasmacytoid DC and chronic hypertension prior to pregnancy was validated. CONCLUSION This study showed that many immunophenotypes are implicated in HDP. Furthermore, the level of LOX-1 mediated the pathophysiology relationship between HLA DR on plasmacytoid dendritic cells and chronic hypertension prior to pregnancy.
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Affiliation(s)
- Jingting Liu
- Maternal and Child Health Care Research Center, Gansu Provincial Maternity and Child Care Hospital, Lanzhou, 730050, China
| | - Yijun Dong
- The Second Hospital & Clinical Medical School, Lanzhou University, Lanzhou, 730000, China
| | - Yawei Zhou
- Maternal and Child Health Care Research Center, Gansu Provincial Maternity and Child Care Hospital, Lanzhou, 730050, China
| | - Wendi Wang
- Maternal and Child Health Care Research Center, Gansu Provincial Maternity and Child Care Hospital, Lanzhou, 730050, China
| | - Yan Li
- Department of Biochemistry and Molecular Biology, Medical College of Northwest Minzu University, Lanzhou, 730030, China.
| | - Jianying Pei
- Maternal and Child Health Care Research Center, Gansu Provincial Maternity and Child Care Hospital, Lanzhou, 730050, China.
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Agarwal M, Leeson P, Kitt J. Can heart failure phenotypes be predicted by cardiac remodelling peripartum or postpartum? Front Cardiovasc Med 2024; 11:1409183. [PMID: 39165262 PMCID: PMC11333610 DOI: 10.3389/fcvm.2024.1409183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Accepted: 07/23/2024] [Indexed: 08/22/2024] Open
Abstract
Hypertension during pregnancy affects up to 10% of pregnancies and is associated with significant cardiovascular morbidity and mortality. In the short-term it can result in pre-eclampsia, haemolysis, elevated liver enzymes and low platelets (HELLP) syndrome, or even hypertension associated acute heart failure, all of which may necessitate pre-term delivery to prevent maternal or neonatal death. In the long term, a history of gestational hypertension and pre-eclampsia significantly increases the risk of future cardiovascular disease including chronic hypertension, coronary artery disease, heart failure and stroke. This review explores our current level of knowledge of the phenotypes of heart failure, paying particular attention to those specific to women, and the role of pregnancy and non-pregnancy related risk factors in the development of this condition. We discuss why women with hypertensive pregnancy may be disproportionately affected by heart failure with preserved ejection fraction (HFpEF) and whether a unique phenotype of heart failure unique to hypertensive pregnancy exists. Finally, we explore how future cardiovascular risk may be predicted based on cardiac remodelling during or after pregnancy and suggest potential areas of further research in the field.
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Affiliation(s)
- Megha Agarwal
- Cardiovascular Clinical Research Facility, RDM Division of Cardiovascular Medicine, University of Oxford, Oxford, United Kingdom
| | - Paul Leeson
- Cardiovascular Clinical Research Facility, RDM Division of Cardiovascular Medicine, University of Oxford, Oxford, United Kingdom
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Falcão-Pires I, Ferreira AF, Trindade F, Bertrand L, Ciccarelli M, Visco V, Dawson D, Hamdani N, Van Laake LW, Lezoualc'h F, Linke WA, Lunde IG, Rainer PP, Abdellatif M, Van der Velden J, Cosentino N, Paldino A, Pompilio G, Zacchigna S, Heymans S, Thum T, Tocchetti CG. Mechanisms of myocardial reverse remodelling and its clinical significance: A scientific statement of the ESC Working Group on Myocardial Function. Eur J Heart Fail 2024; 26:1454-1479. [PMID: 38837573 DOI: 10.1002/ejhf.3264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 03/22/2024] [Accepted: 04/18/2024] [Indexed: 06/07/2024] Open
Abstract
Cardiovascular disease (CVD) is the leading cause of morbimortality in Europe and worldwide. CVD imposes a heterogeneous spectrum of cardiac remodelling, depending on the insult nature, that is, pressure or volume overload, ischaemia, arrhythmias, infection, pathogenic gene variant, or cardiotoxicity. Moreover, the progression of CVD-induced remodelling is influenced by sex, age, genetic background and comorbidities, impacting patients' outcomes and prognosis. Cardiac reverse remodelling (RR) is defined as any normative improvement in cardiac geometry and function, driven by therapeutic interventions and rarely occurring spontaneously. While RR is the outcome desired for most CVD treatments, they often only slow/halt its progression or modify risk factors, calling for novel and more timely RR approaches. Interventions triggering RR depend on the myocardial insult and include drugs (renin-angiotensin-aldosterone system inhibitors, beta-blockers, diuretics and sodium-glucose cotransporter 2 inhibitors), devices (cardiac resynchronization therapy, ventricular assist devices), surgeries (valve replacement, coronary artery bypass graft), or physiological responses (deconditioning, postpartum). Subsequently, cardiac RR is inferred from the degree of normalization of left ventricular mass, ejection fraction and end-diastolic/end-systolic volumes, whose extent often correlates with patients' prognosis. However, strategies aimed at achieving sustained cardiac improvement, predictive models assessing the extent of RR, or even clinical endpoints that allow for distinguishing complete from incomplete RR or adverse remodelling objectively, remain limited and controversial. This scientific statement aims to define RR, clarify its underlying (patho)physiologic mechanisms and address (non)pharmacological options and promising strategies to promote RR, focusing on the left heart. We highlight the predictors of the extent of RR and review the prognostic significance/impact of incomplete RR/adverse remodelling. Lastly, we present an overview of RR animal models and potential future strategies under pre-clinical evaluation.
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Affiliation(s)
- Inês Falcão-Pires
- UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Ana Filipa Ferreira
- UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Fábio Trindade
- UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Luc Bertrand
- Université Catholique de Louvain, Institut de Recherche Expérimentale et Clinique, Pôle of Cardiovascular Research, Brussels, Belgium
- WELBIO, Department, WEL Research Institute, Wavre, Belgium
| | - Michele Ciccarelli
- Cardiovascular Research Unit, Department of Medicine and Surgery, University of Salerno, Baronissi, Italy
| | - Valeria Visco
- Cardiovascular Research Unit, Department of Medicine and Surgery, University of Salerno, Baronissi, Italy
| | - Dana Dawson
- Aberdeen Cardiovascular and Diabetes Centre, School of Medicine and Dentistry, University of Aberdeen, Aberdeen, UK
| | - Nazha Hamdani
- Department of Cellular and Translational Physiology, Institute of Physiology, Ruhr University Bochum, Bochum, Germany
- Institut für Forschung und Lehre (IFL), Molecular and Experimental Cardiology, Ruhr University Bochum, Bochum, Germany
- HCEMM-SU Cardiovascular Comorbidities Research Group, Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
- Department of Physiology, Cardiovascular Research Institute Maastricht University Maastricht, Maastricht, the Netherlands
| | - Linda W Van Laake
- Division Heart and Lungs, Department of Cardiology and Regenerative Medicine Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Frank Lezoualc'h
- Institut des Maladies Métaboliques et Cardiovasculaires, Inserm, Université Paul Sabatier, UMR 1297-I2MC, Toulouse, France
| | - Wolfgang A Linke
- Institute of Physiology II, University Hospital Münster, Münster, Germany
| | - Ida G Lunde
- Oslo Center for Clinical Heart Research, Department of Cardiology, Oslo University Hospital Ullevaal, Oslo, Norway
- KG Jebsen Center for Cardiac Biomarkers, Campus Ahus, University of Oslo, Oslo, Norway
| | - Peter P Rainer
- Division of Cardiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
- BioTechMed Graz, Graz, Austria
- St. Johann in Tirol General Hospital, St. Johann in Tirol, Austria
| | - Mahmoud Abdellatif
- Division of Cardiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
- BioTechMed Graz, Graz, Austria
| | | | - Nicola Cosentino
- Centro Cardiologico Monzino IRCCS, Milan, Italy
- Cardiovascular Section, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Alessia Paldino
- Cardiovascular Biology Laboratory, International Centre for Genetic Engineering and Biotechnology (ICGEB), Trieste, Italy
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Giulio Pompilio
- Centro Cardiologico Monzino IRCCS, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Serena Zacchigna
- Cardiovascular Biology Laboratory, International Centre for Genetic Engineering and Biotechnology (ICGEB), Trieste, Italy
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Stephane Heymans
- Department of Cardiology, CARIM Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, The Netherlands
- Centre of Cardiovascular Research, University of Leuven, Leuven, Belgium
| | - Thomas Thum
- Institute of Molecular and Translational Therapeutic Strategies, Hannover Medical School, Hannover, Germany
| | - Carlo Gabriele Tocchetti
- Department of Translational Medical Sciences (DISMET), Center for Basic and Clinical Immunology Research (CISI), Interdepartmental Center of Clinical and Translational Sciences (CIRCET), Interdepartmental Hypertension Research Center (CIRIAPA), Federico II University, Naples, Italy
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Eghan P, Folson AA, Donkor A, Kokuro C, Amo Wiafe Y. Relationship between hypertensive disorders of pregnancy (HDP) and cardiac remodeling during pregnancy: Systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol 2024; 298:108-115. [PMID: 38749071 DOI: 10.1016/j.ejogrb.2024.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 04/30/2024] [Accepted: 05/07/2024] [Indexed: 06/16/2024]
Abstract
OBJECTIVES Hypertensive disorders of pregnancy (HDP) are among the leading causes of maternal morbidity and mortality. The primary objective of this study was to ascertain whether maternal cardiac remodeling is more prevalent in HDP than normotensive pregnancy and if significant change in aortic root size is involved. The secondary objective was to determine the types of cardiac remodeling often associated with HDP. METHODS A systematic search was conducted across four electronic databases, including Medline, PubMed, Cochrane and EMBASE. The reference lists of selected articles were also searched to ensure no relevant studies were missed. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were followed in this systematic review. RESULTS Out of 5,278 articles identified by the search terms, 9 were eligible for inclusion in the meta-analysis. The investigation unveiled a greater prevalence of maternal cardiac remodeling in HDP than normotensive pregnancies. The commonest type of maternal cardiac remodeling in both HDP and normotensive pregnancies was eccentric left ventricular hypertrophy, followed by concentric left ventricular remodeling which was more specific to HDP. Notably, left atrial diameter was significantly increased in HDP than normotensive pregnancies, suggesting higher prevalence of diastolic dysfunction. Additionally, the aortic root dimension was significantly increased in HDP than normotensive pregnancies. CONCLUSION This study underscores the importance of monitoring cardiac health in pregnancy, particularly in those with hypertensive disorders, in order to mitigate potential complications and improve maternal outcomes. Finally, the risk of aortic dissection that may occur as a long-term effect of aortic root enlargement in women with history of HDP ought to be investigated in future studies.
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Affiliation(s)
- Philip Eghan
- Department of Radiology, University of Ghana Medical Centre, Accra, Ghana; Department of Medical Imaging, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Aba A Folson
- Department of Internal Medicine and Therapeutics, School of Medicine, University of Health and Allied Sciences, Ho, Ghana
| | - Andrew Donkor
- Department of Medical Imaging, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Collins Kokuro
- Department of Medicine, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi Ghana
| | - Yaw Amo Wiafe
- Department of Medical Imaging, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.
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Ambia AM, Nelson DB, Martin RB, Stewart RD. The forgotten ventricle-right ventricular remodeling across pregnancy and postpartum: a report of original research. AJOG GLOBAL REPORTS 2024; 4:100335. [PMID: 38595811 PMCID: PMC11001765 DOI: 10.1016/j.xagr.2024.100335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024] Open
Affiliation(s)
- Anne M. Ambia
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center Dallas, 5323 Harry Hines Blvd., Dallas, TX 75390
| | - David B. Nelson
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center Dallas, 5323 Harry Hines Blvd., Dallas, TX 75390
| | - Robert B. Martin
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center Dallas, 5323 Harry Hines Blvd., Dallas, TX 75390
| | - Robert D. Stewart
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center Dallas, 5323 Harry Hines Blvd., Dallas, TX 75390
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Ferreira AF, Azevedo MJ, Morais J, Almeida-Coelho J, Leite-Moreira AM, Lourenço AP, Saraiva F, Diaz SO, Amador AF, Sousa C, Machado AP, Sampaio-Maia B, Ramalho C, Leite-Moreira A, Barros AS, Falcão-Pires I. Stretch-induced compliance mechanism in pregnancy-induced cardiac hypertrophy and the impact of cardiovascular risk factors. Am J Physiol Heart Circ Physiol 2024; 326:H1193-H1203. [PMID: 38334973 DOI: 10.1152/ajpheart.00701.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 01/30/2024] [Accepted: 01/31/2024] [Indexed: 02/10/2024]
Abstract
Pressure overload-induced hypertrophy compromises cardiac stretch-induced compliance (SIC) after acute volume overload (AVO). We hypothesized that SIC could be enhanced by physiological hypertrophy induced by pregnancy's chronic volume overload. This study evaluated SIC-cardiac adaptation in pregnant women with or without cardiovascular risk (CVR) factors. Thirty-seven women (1st trimester, 1stT) and a separate group of 31 (3rd trimester, 3rdT) women [healthy or with CVR factors (obesity and/or hypertension and/or with gestational diabetes)] underwent echocardiography determination of left ventricular end-diastolic volume (LVEDV) and E/e' before (T0), immediately after (T1), and 15 min after (T2; SIC) AVO induced by passive leg elevation. Blood samples for NT-proBNP quantification were collected before and after the AVO. Acute leg elevation significantly increased inferior vena cava diameter and stroke volume from T0 to T1 in both 1stT and 3rdT, confirming AVO. LVEDV and E/e' also increased immediately after AVO (T1) in both 1stT and 3rdT. SIC adaptation (T2, 15 min after AVO) significantly decreased E/e' in both trimesters, with additional expansion of LVEDV only in the 1stT. NT-pro-BNP increased slightly after AVO but only in the 1stT. CVR factors, but not parity or age, significantly impacted SIC cardiac adaptation. A distinct functional response to SIC was observed between 1stT and 3rdT, which was influenced by CVR factors. The LV of 3rdT pregnant women was hypertrophied, showing a structural limitation to dilate with AVO, whereas the lower LV filling pressure values suggest increased diastolic compliance.NEW & NOTEWORTHY The sudden increase of volume overload triggers an acute myocardial stretch characterized by an immediate rise in contractility by the Frank-Starling mechanism, followed by a progressive increase known as the slow force response. The present study is the first to characterize echocardiographically the stretch-induced compliance (SIC) mechanism in the context of physiological hypertrophy induced by pregnancy. A distinct functional adaptation to SIC was observed between first and third trimesters, which was influenced by cardiovascular risk factors.
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Affiliation(s)
- Ana Filipa Ferreira
- Cardiovascular Research and Development Unit, Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Maria João Azevedo
- Faculdade de Medicina Dentária, Universidade do Porto, Porto, Portugal
- Instituto Nacional de Engenharia Biomédica, Porto, Portugal
- i3S-Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
- Academic Center for Dentistry Amsterdam, University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Juliana Morais
- Cardiovascular Research and Development Unit, Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal
| | - João Almeida-Coelho
- Cardiovascular Research and Development Unit, Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal
| | - André M Leite-Moreira
- Cardiovascular Research and Development Unit, Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal
- Anesthesiology Department, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - André P Lourenço
- Cardiovascular Research and Development Unit, Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal
- Anesthesiology Department, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Francisca Saraiva
- Cardiovascular Research and Development Unit, Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Sílvia O Diaz
- Cardiovascular Research and Development Unit, Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Ana Filipa Amador
- Cardiology Department, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Carla Sousa
- Cardiovascular Research and Development Unit, Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal
- Cardiology Department, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Ana Paula Machado
- Obstetrics Department, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Benedita Sampaio-Maia
- Faculdade de Medicina Dentária, Universidade do Porto, Porto, Portugal
- Instituto Nacional de Engenharia Biomédica, Porto, Portugal
- i3S-Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
| | - Carla Ramalho
- i3S-Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
- Obstetrics Department, Centro Hospitalar Universitário de São João, Porto, Portugal
- Obstetrics, Gynaecology and Pediatrics Department, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Adelino Leite-Moreira
- Cardiovascular Research and Development Unit, Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal
- Cardiothoracic Surgery Department, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - António S Barros
- Cardiovascular Research and Development Unit, Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Inês Falcão-Pires
- Cardiovascular Research and Development Unit, Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal
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Lihme FF, Basit S, Persson LG, Larsen MO, Lauridsen KH, Lykke JA, Andersen AS, Halse K, Thorsen-Meyer A, Melbye M, Wohlfahrt J, Boyd HA. Reference ranges for third-trimester maternal cardiovascular function parameters measured in normotensive pregnant women using a non-invasive cardiac output monitor: A study based on data from the prospective PEACH cohort study. BJOG 2024; 131:463-471. [PMID: 37735094 PMCID: PMC10938999 DOI: 10.1111/1471-0528.17667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 08/23/2023] [Accepted: 09/02/2023] [Indexed: 09/23/2023]
Abstract
OBJECTIVE We defined reference ranges for maternal cardiac output, systemic vascular resistance, and stroke volume measured in the third trimester of pregnancy using the Ultrasound Cardiac Output Monitor 1A. DESIGN Based on data from the prospective PEACH (PreEclampsia, Angiogenesis, Cardiac dysfunction and Hypertension) cohort study. SETTING Rigshospitalet and Hvidovre Hospital, Denmark. SAMPLE Normotensive pregnant women aged 18-45 years with singleton pregnancies, enrolled in the PEACH study in 2016-2018. METHODS We modelled cardiac output, systemic vascular resistance and stroke volume as a function of gestational age using multilevel linear models with fractional polynomials. MAIN OUTCOME MEASURES Unconditional and conditional reference ranges for cardiovascular parameters measured in gestational weeks 28-40. RESULTS Our study cohort included 405 healthy pregnant women who contributed 1210 cardiovascular function measurements for analysis. Maximum cardiac output and stroke volume values were measured in gestational weeks 30-32 and decreased over the third trimester, whereas systemic vascular resistance increased during the same period. We created reference ranges for eight combinations of maternal height, age and parity. We also created a simple calculator to allow for implementation of the reference ranges in clinical practice. CONCLUSIONS Our reference ranges allow the use of a bedside ultrasound device to non-invasively assess cardiac function in pregnancy and identify women at risk of complications. The unconditional ranges allow clinicians to evaluate isolated measurements and identify women needing follow-up. The conditional ranges incorporate information from previous measurements and improve monitoring over time.
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Affiliation(s)
- Frederikke F. Lihme
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
| | - Saima Basit
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
| | - Lisa G. Persson
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
| | - Maria O. Larsen
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
| | - Karin H. Lauridsen
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
| | - Jacob A. Lykke
- Department of Gynaecology and Obstetrics, Rigshospitalet, Copenhagen, Denmark
| | - Anita S. Andersen
- Department of Gynaecology and Obstetrics, Hvidovre Hospital, Copenhagen, Denmark
- Department of Obstetrics, Copenhagen University Hospital Herlev, Denmark
| | - Karen Halse
- Department of Gynaecology and Obstetrics, Hvidovre Hospital, Copenhagen, Denmark
| | | | - Mads Melbye
- Danish Cancer Society Research Center, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jan Wohlfahrt
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
| | - Heather A. Boyd
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
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Kitt J, Krasner S, Barr L, Frost A, Tucker K, Bateman PA, Suriano K, Kenworthy Y, Lapidaire W, Lacharie M, Mills R, Roman C, Mackillop L, Cairns A, Aye C, Ferreira V, Piechnik S, Lukaschuk E, Thilaganathan B, Chappell LC, Lewandowski AJ, McManus RJ, Leeson P. Cardiac Remodeling After Hypertensive Pregnancy Following Physician-Optimized Blood Pressure Self-Management: The POP-HT Randomized Clinical Trial Imaging Substudy. Circulation 2024; 149:529-541. [PMID: 37950907 DOI: 10.1161/circulationaha.123.067597] [Citation(s) in RCA: 27] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Accepted: 11/09/2023] [Indexed: 11/13/2023]
Abstract
BACKGROUND Hypertensive pregnancy disorders are associated with adverse cardiac remodeling, which can fail to reverse in the postpartum period in some women. The Physician-Optimized Postpartum Hypertension Treatment trial demonstrated that improved blood pressure control while the cardiovascular system recovers postpartum associates with persistently reduced blood pressure. We now report the effect on cardiac remodeling. METHODS In this prospective, randomized, open-label, blinded end point trial, in a single UK hospital, 220 women were randomly assigned 1:1 to self-monitoring with research physician-optimized antihypertensive titration or usual postnatal care from a primary care physician and midwife. Participants were 18 years of age or older, with preeclampsia or gestational hypertension, requiring antihypertensives on hospital discharge postnatally. Prespecified secondary cardiac imaging outcomes were recorded by echocardiography around delivery, and again at blood pressure primary outcome assessment, around 9 months postpartum, when cardiovascular magnetic resonance was also performed. RESULTS A total of 187 women (101 intervention; 86 usual care) underwent echocardiography at baseline and follow-up, at a mean 258±14.6 days postpartum, of which 174 (93 intervention; 81 usual care) also had cardiovascular magnetic resonance at follow-up. Relative wall thickness by echocardiography was 0.06 (95% CI, 0.07-0.05; P<0.001) lower in the intervention group between baseline and follow-up, and cardiovascular magnetic resonance at follow-up demonstrated a lower left ventricular mass (-6.37 g/m2; 95% CI, -7.99 to -4.74; P<0.001), end-diastolic volume (-3.87 mL/m2; 95% CI, -6.77 to -0.98; P=0.009), and end-systolic volume (-3.25 mL/m2; 95% CI, 4.87 to -1.63; P<0.001) and higher left and right ventricular ejection fraction by 2.6% (95% CI, 1.3-3.9; P<0.001) and 2.8% (95% CI, 1.4-4.1; P<0.001), respectively. Echocardiography-assessed left ventricular diastolic function demonstrated a mean difference in average E/E' of 0.52 (95% CI, -0.97 to -0.07; P=0.024) and a reduction in left atrial volumes of -4.33 mL/m2 (95% CI, -5.52 to -3.21; P<0.001) between baseline and follow-up when adjusted for baseline differences in measures. CONCLUSIONS Short-term postnatal optimization of blood pressure control after hypertensive pregnancy, through self-monitoring and physician-guided antihypertensive titration, associates with long-term changes in cardiovascular structure and function, in a pattern associated with more favorable cardiovascular outcomes. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT04273854.
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Affiliation(s)
- Jamie Kitt
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine (J.K., S.K., A.F., K.S., Y.K., W.L., A.J.L., P.L.), University of Oxford, United Kingdom
- Nuffield Department of Primary Care Health Sciences (J.K., K.T., P.A.B., R.J.M.), University of Oxford, United Kingdom
| | - Samuel Krasner
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine (J.K., S.K., A.F., K.S., Y.K., W.L., A.J.L., P.L.), University of Oxford, United Kingdom
| | - Logan Barr
- Queen's University School of Medicine, Kingston, Canada (L.B.)
| | - Annabelle Frost
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine (J.K., S.K., A.F., K.S., Y.K., W.L., A.J.L., P.L.), University of Oxford, United Kingdom
- Nuffield Department of Women's and Reproductive Health (A.F., L.M., A.C., C.A.), University of Oxford, United Kingdom
| | - Katherine Tucker
- Nuffield Department of Primary Care Health Sciences (J.K., K.T., P.A.B., R.J.M.), University of Oxford, United Kingdom
| | - Paul A Bateman
- Nuffield Department of Primary Care Health Sciences (J.K., K.T., P.A.B., R.J.M.), University of Oxford, United Kingdom
| | - Katie Suriano
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine (J.K., S.K., A.F., K.S., Y.K., W.L., A.J.L., P.L.), University of Oxford, United Kingdom
| | - Yvonne Kenworthy
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine (J.K., S.K., A.F., K.S., Y.K., W.L., A.J.L., P.L.), University of Oxford, United Kingdom
| | - Winok Lapidaire
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine (J.K., S.K., A.F., K.S., Y.K., W.L., A.J.L., P.L.), University of Oxford, United Kingdom
| | - Miriam Lacharie
- Oxford Centre for Clinical Magnetic Resonance Research, Division of Cardiovascular Medicine, Radcliffe Department of Medicine (M.L., R.M., S.P.), University of Oxford, United Kingdom
| | - Rebecca Mills
- Oxford Centre for Clinical Magnetic Resonance Research, Division of Cardiovascular Medicine, Radcliffe Department of Medicine (M.L., R.M., S.P.), University of Oxford, United Kingdom
| | - Cristian Roman
- Institute of Biomedical Engineering, Department of Engineering Science (C.R.), University of Oxford, United Kingdom
| | - Lucy Mackillop
- Nuffield Department of Women's and Reproductive Health (A.F., L.M., A.C., C.A.), University of Oxford, United Kingdom
| | - Alexandra Cairns
- Nuffield Department of Women's and Reproductive Health (A.F., L.M., A.C., C.A.), University of Oxford, United Kingdom
| | - Christina Aye
- Nuffield Department of Women's and Reproductive Health (A.F., L.M., A.C., C.A.), University of Oxford, United Kingdom
- Fetal Medicine Unit, Oxford University Hospitals National Health Service Foundation Trust, United Kingdom (C.A.)
| | - Vanessa Ferreira
- Oxford Centre for Clinical Magnetic Resonance Research (V.F., E.L.), University of Oxford, United Kingdom
| | - Stefan Piechnik
- Oxford Centre for Clinical Magnetic Resonance Research, Division of Cardiovascular Medicine, Radcliffe Department of Medicine (M.L., R.M., S.P.), University of Oxford, United Kingdom
| | - Elena Lukaschuk
- Oxford Centre for Clinical Magnetic Resonance Research (V.F., E.L.), University of Oxford, United Kingdom
| | - Basky Thilaganathan
- Fetal Medicine Unit, St George's University Hospitals National Health Service Foundation Trust, London, United Kingdom (B.T.)
- Molecular and Clinical Sciences Research Institute, St George's University of London, United Kingdom (B.T.)
| | - Lucy C Chappell
- King's College London and Guy's and St Thomas' National Health Service Foundation Trust, United Kingdom (L.C.C.)
| | - Adam J Lewandowski
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine (J.K., S.K., A.F., K.S., Y.K., W.L., A.J.L., P.L.), University of Oxford, United Kingdom
| | - Richard J McManus
- Nuffield Department of Primary Care Health Sciences (J.K., K.T., P.A.B., R.J.M.), University of Oxford, United Kingdom
| | - Paul Leeson
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine (J.K., S.K., A.F., K.S., Y.K., W.L., A.J.L., P.L.), University of Oxford, United Kingdom
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13
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Giorgione V, Di Fabrizio C, Giallongo E, Khalil A, O'Driscoll J, Whitley G, Kennedy G, Murdoch CE, Thilaganathan B. Angiogenic markers and maternal echocardiographic indices in women with hypertensive disorders of pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 63:206-213. [PMID: 37675647 DOI: 10.1002/uog.27474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 08/11/2023] [Accepted: 08/24/2023] [Indexed: 09/08/2023]
Abstract
OBJECTIVE The maternal cardiovascular system of women with hypertensive disorders of pregnancy (HDP) can be impaired, with higher rates of left ventricular (LV) remodeling and diastolic dysfunction compared to those with normotensive pregnancy. The primary objective of this prospective study was to correlate cardiac indices obtained by transthoracic echocardiography (TTE) and circulating angiogenic markers, such as soluble fms-like tyrosine kinase-1 (sFlt-1) and placental growth factor (PlGF). METHODS In this study, 95 women with a pregnancy complicated by HDP and a group of 25 with an uncomplicated pregnancy at term underwent TTE and blood tests to measure sFlt-1 and PlGF during the peripartum period (before delivery or within a week of giving birth). Spearman's rank correlation was used to derive correlation coefficients between biomarkers and cardiac indices in the HDP and control populations. RESULTS The HDP group included 61 (64.2%) pre-eclamptic patients and, among them, 42 (68.9%) delivered before 37 weeks' gestation. Twelve women with HDP (12.6%) underwent blood sampling and TTE after delivery, and, as they showed significantly lower levels of angiogenic markers, they were excluded from the analysis. There was a correlation between sFlt-1 and LV mass index (LVMI) (r = 0.246; P = 0.026) and early diastolic mitral inflow velocity (E) and early diastolic mitral annular velocity (e') ratio (r = 0.272; P = 0.014) in the HDP group (n = 83), while in the controls, sFlt-1 showed a correlation with relative wall thickness (r = 0.409; P = 0.043), lateral e' (r = -0.562; P = 0.004) and E/e' ratio (r = 0.417; P = 0.042). PlGF correlated with LVMI (r = -0.238; P = 0.031) in HDP patients and with lateral e' (r = 0.466; P = 0.022) in controls. sFlt-1/PlGF ratio correlated with lateral e' (r = -0.568; P = 0.004) and E/e' ratio (r = 0.428; P = 0.037) in controls and with LVMI (r = 0.252; P = 0.022) and E/e' ratio (r = 0.269; P = 0.014) in HDP. CONCLUSIONS Although the current data are not able to infer causality, they confirm the intimate relationship between the maternal cardiovascular system and angiogenic markers that are used both to diagnose and indicate the severity of HDP. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- V Giorgione
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - C Di Fabrizio
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Division of Systems Medicine, School of Medicine, University of Dundee, Dundee, UK
| | - E Giallongo
- Intensive Care National Audit & Research Centre, London, UK
| | - A Khalil
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - J O'Driscoll
- Department of Cardiology, St George's University Hospitals NHS Foundation Trust, London, UK
- School of Psychology and Life Sciences, Canterbury Christ Church University, Kent, UK
| | - G Whitley
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - G Kennedy
- Immunoassay Biomarker Core Laboratory, School of Medicine, University of Dundee, Dundee, UK
| | - C E Murdoch
- Division of Systems Medicine, School of Medicine, University of Dundee, Dundee, UK
| | - B Thilaganathan
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
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14
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Ferreira AF, Azevedo MJ, Morais J, Trindade F, Saraiva F, Diaz SO, Alves IN, Fragão-Marques M, Sousa C, Machado AP, Leite-Moreira A, Sampaio-Maia B, Ramalho C, Barros AS, Falcão-Marques I. Cardiovascular risk factors during pregnancy impact the postpartum cardiac and vascular reverse remodeling. Am J Physiol Heart Circ Physiol 2023; 325:H774-H789. [PMID: 37477690 DOI: 10.1152/ajpheart.00200.2023] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 07/06/2023] [Accepted: 07/06/2023] [Indexed: 07/22/2023]
Abstract
Pregnant women with cardiovascular risk (CVR) factors are highly prone to develop cardiovascular disease later in life. Thus, recent guidelines suggest extending the follow-up period to 1 yr after delivery. We aimed to evaluate cardiovascular remodeling during pregnancy and determine which CVR factors and potential biomarkers predict postpartum cardiac and vascular reverse remodeling (RR). Our study included a prospective cohort of 76 healthy and 54 obese and/or hypertensive and/or with gestational diabetes pregnant women who underwent transthoracic echocardiography, pulse-wave velocity (PWV), and blood collection at the 1st trimester (1T) and 3rd trimester (3T) of pregnancy as well as at the 1st/6th/12th mo after delivery. Generalized linear mixed-effects models was used to evaluate the extent of RR and its potential predictors. Pregnant women develop cardiac hypertrophy, as confirmed by a significant increase in left ventricular mass (LVM). Moreover, ventricular filling pressure (E/e') and atrial volume increased significantly during gestation. Significant regression of left ventricular (LV) volume, LVM, and filling pressures was observed as soon as 1 mo postpartum. The LV global longitudinal strain worsened slightly and recovered at 6 mo postpartum. PWV decreased significantly from 1T to 3T and normalized at 1 mo postpartum. We found that arterial hypertension, smoking habits, and obesity were independent predictors of increased LVM during pregnancy and postpartum. High C-reactive protein (CRP) and low ST2/IL33-receptor levels are potential circulatory biomarkers of worse LVM regression. Arterial hypertension, age, and gestational diabetes positively correlated with PWV. Altogether, our findings pinpoint arterial hypertension as a critical risk factor for worse RR and CRP, and ST2/IL33 receptors as potential biomarkers of postpartum hypertrophy reversal.NEW & NOTEWORTHY This study describes the impact of cardiovascular risk factors (CVR) in pregnancy-induced remodeling and postpartum reverse remodeling (up to 1 yr) by applying advanced statistic methods (multivariate generalized linear mixed-effects models) to a prospective cohort of pregnant women. Aiming to extrapolate to pathological conditions, this invaluable "human model" allowed us to demonstrate that arterial hypertension is a critical CVR for worse RR and that ST2/IL33-receptors and CRP are potential biomarkers of postpartum hypertrophy reversal.
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Affiliation(s)
- Ana Filipa Ferreira
- Department of Surgery and Physiology, Cardiovascular R&D Centre-UnIC@RISE, Faculdade de Medicina, University of Porto, Porto, Portugal
| | - Maria João Azevedo
- Faculdade de Medicina Dentária, Universidade do Porto, Porto, Portugal
- INEB-Instituto Nacional de Engenharia Biomédica, Porto, Portugal
- i3S-Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
- Academic Center for Dentistry Amsterdam, University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Juliana Morais
- Department of Surgery and Physiology, Cardiovascular R&D Centre-UnIC@RISE, Faculdade de Medicina, University of Porto, Porto, Portugal
| | - Fábio Trindade
- Department of Surgery and Physiology, Cardiovascular R&D Centre-UnIC@RISE, Faculdade de Medicina, University of Porto, Porto, Portugal
| | - Francisca Saraiva
- Department of Surgery and Physiology, Cardiovascular R&D Centre-UnIC@RISE, Faculdade de Medicina, University of Porto, Porto, Portugal
| | - Sílvia Oliveira Diaz
- Department of Surgery and Physiology, Cardiovascular R&D Centre-UnIC@RISE, Faculdade de Medicina, University of Porto, Porto, Portugal
| | - Inês Nuno Alves
- Department of Surgery and Physiology, Cardiovascular R&D Centre-UnIC@RISE, Faculdade de Medicina, University of Porto, Porto, Portugal
| | - Mariana Fragão-Marques
- Department of Surgery and Physiology, Cardiovascular R&D Centre-UnIC@RISE, Faculdade de Medicina, University of Porto, Porto, Portugal
- Department of Clinical Pathology, Centro Hospitalar de São João, Porto, Portugal
| | - Carla Sousa
- Department of Surgery and Physiology, Cardiovascular R&D Centre-UnIC@RISE, Faculdade de Medicina, University of Porto, Porto, Portugal
- Department of Cardiology, Centro Hospitalar de São João, Porto, Portugal
| | - Ana Paula Machado
- Center of Prenatal Diagnosis, Department of Obstetrics, Centro Hospitalar de São João, Porto, Portugal
| | - Adelino Leite-Moreira
- Department of Surgery and Physiology, Cardiovascular R&D Centre-UnIC@RISE, Faculdade de Medicina, University of Porto, Porto, Portugal
- Department of Cardiothoracic Surgery, Centro Hospitalar de São João, Porto, Portugal
| | - Benedita Sampaio-Maia
- Faculdade de Medicina Dentária, Universidade do Porto, Porto, Portugal
- INEB-Instituto Nacional de Engenharia Biomédica, Porto, Portugal
- i3S-Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
| | - Carla Ramalho
- Center of Prenatal Diagnosis, Department of Obstetrics, Centro Hospitalar de São João, Porto, Portugal
- Department of Obstetrics, Gynaecology and Pediatrics, Faculty of Medicine, University of Porto, Porto, Portugal
| | - António Sousa Barros
- Department of Surgery and Physiology, Cardiovascular R&D Centre-UnIC@RISE, Faculdade de Medicina, University of Porto, Porto, Portugal
| | - Inês Falcão-Marques
- Department of Surgery and Physiology, Cardiovascular R&D Centre-UnIC@RISE, Faculdade de Medicina, University of Porto, Porto, Portugal
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15
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Diniz MS, Grilo LF, Tocantins C, Falcão-Pires I, Pereira SP. Made in the Womb: Maternal Programming of Offspring Cardiovascular Function by an Obesogenic Womb. Metabolites 2023; 13:845. [PMID: 37512552 PMCID: PMC10386510 DOI: 10.3390/metabo13070845] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 07/02/2023] [Accepted: 07/07/2023] [Indexed: 07/30/2023] Open
Abstract
Obesity incidence has been increasing at an alarming rate, especially in women of reproductive age. It is estimated that 50% of pregnancies occur in overweight or obese women. It has been described that maternal obesity (MO) predisposes the offspring to an increased risk of developing many chronic diseases in an early stage of life, including obesity, type 2 diabetes, and cardiovascular disease (CVD). CVD is the main cause of death worldwide among men and women, and it is manifested in a sex-divergent way. Maternal nutrition and MO during gestation could prompt CVD development in the offspring through adaptations of the offspring's cardiovascular system in the womb, including cardiac epigenetic and persistent metabolic programming of signaling pathways and modulation of mitochondrial metabolic function. Currently, despite diet supplementation, effective therapeutical solutions to prevent the deleterious cardiac offspring function programming by an obesogenic womb are lacking. In this review, we discuss the mechanisms by which an obesogenic intrauterine environment could program the offspring's cardiovascular metabolism in a sex-divergent way, with a special focus on cardiac mitochondrial function, and debate possible strategies to implement during MO pregnancy that could ameliorate, revert, or even prevent deleterious effects of MO on the offspring's cardiovascular system. The impact of maternal physical exercise during an obesogenic pregnancy, nutritional interventions, and supplementation on offspring's cardiac metabolism are discussed, highlighting changes that may be favorable to MO offspring's cardiovascular health, which might result in the attenuation or even prevention of the development of CVD in MO offspring. The objectives of this manuscript are to comprehensively examine the various aspects of MO during pregnancy and explore the underlying mechanisms that contribute to an increased CVD risk in the offspring. We review the current literature on MO and its impact on the offspring's cardiometabolic health. Furthermore, we discuss the potential long-term consequences for the offspring. Understanding the multifaceted effects of MO on the offspring's health is crucial for healthcare providers, researchers, and policymakers to develop effective strategies for prevention and intervention to improve care.
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Affiliation(s)
- Mariana S Diniz
- CNC-Center for Neuroscience and Cell Biology, CIBB-Centre for Innovative Biomedicine and Biotechnology, University of Coimbra, 3004-531 Coimbra, Portugal
- Ph.D. Programme in Experimental Biology and Biomedicine (PDBEB), Institute for Interdisciplinary Research (IIIUC), University of Coimbra, 3004-531 Coimbra, Portugal
| | - Luís F Grilo
- CNC-Center for Neuroscience and Cell Biology, CIBB-Centre for Innovative Biomedicine and Biotechnology, University of Coimbra, 3004-531 Coimbra, Portugal
- Ph.D. Programme in Experimental Biology and Biomedicine (PDBEB), Institute for Interdisciplinary Research (IIIUC), University of Coimbra, 3004-531 Coimbra, Portugal
| | - Carolina Tocantins
- CNC-Center for Neuroscience and Cell Biology, CIBB-Centre for Innovative Biomedicine and Biotechnology, University of Coimbra, 3004-531 Coimbra, Portugal
- Ph.D. Programme in Experimental Biology and Biomedicine (PDBEB), Institute for Interdisciplinary Research (IIIUC), University of Coimbra, 3004-531 Coimbra, Portugal
| | - Inês Falcão-Pires
- UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine, University of Porto, 4099-002 Porto, Portugal
| | - Susana P Pereira
- CNC-Center for Neuroscience and Cell Biology, CIBB-Centre for Innovative Biomedicine and Biotechnology, University of Coimbra, 3004-531 Coimbra, Portugal
- Laboratory of Metabolism and Exercise (LaMetEx), Research Centre in Physical Activity, Health and Leisure (CIAFEL), Laboratory for Integrative and Translational Research in Population Health (ITR), Faculty of Sports, University of Porto, 4200-450 Porto, Portugal
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16
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Appiah LT, Gyabaah S, Adu-Boakye Y, Nkum BC. Undiagnosed sub-valvular aortic stenosis with an associated Ventricular Septal Defect (VSD) presenting late in a multi-parous woman. BMC Cardiovasc Disord 2023; 23:200. [PMID: 37072741 PMCID: PMC10111744 DOI: 10.1186/s12872-023-03242-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 04/13/2023] [Indexed: 04/20/2023] Open
Abstract
BACKGROUND Sub-valvular aortic stenosis is a rare disorder that has a prevalence of 6.5% of all adult congenital heart diseases. The hemodynamic changes that occur in pregnancy with the resultant increase in cardiac output may not well be tolerated by a pregnant woman with sub-valvular aortic stenosis. CASE PRESENTATION We report the case of a 34-year-old para 7 (6 alive + 1 dead) who has been experiencing intermittent episodes of easy fatigability on moderate exertion since childhood and had survived 6 prior pregnancies. During her last pregnancy, she started experiencing chest pain, palpitations, dyspnea, orthopnea, and pre-syncope at 36 weeks and had a caesarean section at 37 weeks on account of fetal distress. The post-delivery cardiac evaluation showed severe sub-valvular Aortic stenosis and a ventricular septal defect. CONCLUSION Sub-valvular Aortic stenosis may progress slowly in adults and may be tolerated during pregnancy. Despite the rare presentation and contraindication of pregnancy in such a patient, she extraordinarily survived the pregnancy with a healthy baby. Routine cardiovascular assessment during prenatal, ante-natal and post-natal care is highly advocated particularly so in resource-poor settings.
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Affiliation(s)
- Lambert Tetteh Appiah
- Kwame Nkrumah University of Science and Technology, School of Medicine and Dentistry (KNUST-SMD), Kumasi, Ghana
- Komfo Anokye Teaching Hospital (KATH), P.O BOX 1934, Kumasi, Ghana
| | - Solomon Gyabaah
- Komfo Anokye Teaching Hospital (KATH), P.O BOX 1934, Kumasi, Ghana.
| | - Yaw Adu-Boakye
- Kwame Nkrumah University of Science and Technology, School of Medicine and Dentistry (KNUST-SMD), Kumasi, Ghana
- Komfo Anokye Teaching Hospital (KATH), P.O BOX 1934, Kumasi, Ghana
| | - Bernard C Nkum
- Kwame Nkrumah University of Science and Technology, School of Medicine and Dentistry (KNUST-SMD), Kumasi, Ghana
- Komfo Anokye Teaching Hospital (KATH), P.O BOX 1934, Kumasi, Ghana
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17
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Castleman JS, Shantsila A, Brown RA, Shantsila E, Lip GYH. Altered cardiac and vascular stiffness in pregnancy after a hypertensive pregnancy. J Hum Hypertens 2023; 37:189-196. [PMID: 35217785 PMCID: PMC9995268 DOI: 10.1038/s41371-022-00662-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 01/25/2022] [Accepted: 02/10/2022] [Indexed: 11/09/2022]
Abstract
Hypertensive disorders of pregnancy are an important cause of morbidity and mortality, impacting on both maternal and fetal wellbeing. Affected women are at higher risk of future cardiovascular morbidity and mortality. Our study objective was to assess differences in cardiovascular function in pregnant women previously affected by gestational hypertension or preeclampsia. Pregnant women diagnosed with gestational hypertension or preeclampsia in a previous pregnancy were recruited at the start of a subsequent pregnancy and compared to healthy pregnant and non-pregnant controls. All patients underwent pulse wave analysis and echocardiography. Indexes of echocardiography-derived arterial and left ventricular elastance were calculated. In our study women with prior hypertension (n = 25) were more likely to have blood pressure in the 120-139/80-99 mmHg (prehypertension) range. Women with previous hypertension in pregnancy had increased late diastolic transmitral flow velocities (A wave) and increased augmentation index. Women without prior hypertension (n = 50) demonstrated more compliance (reduced EaI and Ees) compared to the non-pregnant controls (n = 40). This adaptation was not seen in pregnancy with prior hypertension, where increased arterial stiffness was observed. In conclusion we have shown increased prevalence of prehypertension and increased arterial stiffness in pregnant women previously affected by gestational hypertensive disease. An increased atrial component to ventricular filling reflects altered diastolic function after hypertensive pregnancy. These women are at increased future cardiovascular risk due to altered cardiac and vascular function and require effective risk mitigation.
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Affiliation(s)
- James S Castleman
- West Midlands Fetal Medicine Centre, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, UK.,University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, UK
| | - Alena Shantsila
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.
| | - Richard A Brown
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, UK.,Northumbria Healthcare NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Eduard Shantsila
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Primary Care and Mental Health, University of Liverpool, Liverpool, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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18
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Ormesher L, Vause S, Higson S, Roberts A, Clarke B, Curtis S, Ordonez V, Ansari F, Everett TR, Hordern C, Mackillop L, Stern V, Bonnett T, Reid A, Wallace S, Oyekan E, Douglas H, Cauldwell M, Reddy M, Palmer K, Simpson M, Brennand J, Minns L, Freeman L, Murray S, Mary N, Castleman J, Morris KR, Haslett E, Cassidy C, Johnstone ED, Myers JE. Prevalence of pre-eclampsia and adverse pregnancy outcomes in women with pre-existing cardiomyopathy: a multi-centre retrospective cohort study. Sci Rep 2023; 13:153. [PMID: 36599871 DOI: 10.1038/s41598-022-26606-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 12/16/2022] [Indexed: 01/05/2023] Open
Abstract
Pre-eclampsia is associated with postnatal cardiac dysfunction; however, the nature of this relationship remains uncertain. This multicentre retrospective cohort study aimed to determine the prevalence of pre-eclampsia in women with pre-existing cardiac dysfunction (left ventricular ejection fraction < 55%) and explore the relationship between pregnancy outcome and pre-pregnancy cardiac phenotype. In this cohort of 282 pregnancies, pre-eclampsia prevalence was not significantly increased (4.6% [95% C.I 2.2-7.0%] vs. population prevalence of 4.6% [95% C.I. 2.7-8.2], p = 0.99); 12/13 women had concurrent obstetric/medical risk factors for pre-eclampsia. The prevalence of preterm pre-eclampsia (< 37 weeks) and fetal growth restriction (FGR) was increased (1.8% vs. 0.7%, p = 0.03; 15.2% vs. 5.5%, p < 0.001, respectively). Neither systolic nor diastolic function correlated with pregnancy outcome. Antenatal ß blockers (n = 116) were associated with lower birthweight Z score (adjusted difference - 0.31 [95% C.I. - 0.61 to - 0.01], p = 0.04). To conclude, this study demonstrated a modest increase in preterm pre-eclampsia and significant increase in FGR in women with pre-existing cardiac dysfunction. Our results do not necessarily support a causal relationship between cardiac dysfunction and pre-eclampsia, especially given the population's background risk status. The mechanism underpinning the relationship between cardiac dysfunction and FGR merits further research but could be influenced by concomitant ß blocker use.
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Affiliation(s)
- Laura Ormesher
- Maternal & Fetal Health Research Centre, Division of Developmental Biology and Medicine, University of Manchester, Manchester, UK. .,Saint Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, UK.
| | - Sarah Vause
- Saint Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Suzanne Higson
- Manchester Heart Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | - Anna Roberts
- Saint Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Bernard Clarke
- Manchester Heart Centre, Manchester University NHS Foundation Trust, Manchester, UK.,Division of Cardiovascular Sciences, University of Manchester, Manchester, UK
| | | | | | | | | | - Claire Hordern
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Lucy Mackillop
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Victoria Stern
- Academic Unit of Developmental and Reproductive Medicine, University of Sheffield, Sheffield, UK
| | - Tessa Bonnett
- Academic Unit of Developmental and Reproductive Medicine, University of Sheffield, Sheffield, UK
| | - Alice Reid
- Department of Obstetrics, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Suzanne Wallace
- Department of Obstetrics, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Ebruba Oyekan
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | | | - Maya Reddy
- Monash Women's, Monash Health, Monash University, Melbourne, Australia
| | - Kirsten Palmer
- Monash Women's, Monash Health, Monash University, Melbourne, Australia
| | - Maggie Simpson
- Scottish Adult Congenital Cardiac Service, Golden Jubilee National Hospital, Glasgow, UK
| | - Janet Brennand
- Scottish Adult Congenital Cardiac Service, Golden Jubilee National Hospital, Glasgow, UK.,Queen Elizabeth University Hospital, NHS Greater Glasgow & Clyde, Glasgow, UK
| | - Laura Minns
- Department of Cardiology, Norfolk& Norwich University Hospital Foundation Trust, Norwich, UK
| | - Leisa Freeman
- Department of Cardiology, Norfolk& Norwich University Hospital Foundation Trust, Norwich, UK
| | - Sarah Murray
- Royal Infirmary of Edinburgh, NHS Lothian University Hospitals Division, Edinburgh, UK
| | - Nirmala Mary
- Royal Infirmary of Edinburgh, NHS Lothian University Hospitals Division, Edinburgh, UK
| | - James Castleman
- Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - Katie R Morris
- Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, UK.,Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | | | - Edward D Johnstone
- Maternal & Fetal Health Research Centre, Division of Developmental Biology and Medicine, University of Manchester, Manchester, UK.,Saint Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Jenny E Myers
- Maternal & Fetal Health Research Centre, Division of Developmental Biology and Medicine, University of Manchester, Manchester, UK.,Saint Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
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19
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Dela Justina V, Dos Passos Júnior RR, Lima VV, Giachini FR. Evidence of Nitric Oxide Impairment During Hypertensive Pregnancies. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2023; 1428:99-125. [PMID: 37466771 DOI: 10.1007/978-3-031-32554-0_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
Hypertensive disorders of pregnancy complicate up to 10% of pregnancies worldwide, and they can be classified into (1) gestational hypertension, (2) preeclampsia, (3) chronic hypertension and (4) chronic hypertension with preeclampsia. Nitric oxide (NO) plays an essential role in the haemodynamic adaptations observed during pregnancy. It has been shown that the nitric oxide pathway's dysfunction during pregnancy is associated with placental- and vascular-related diseases such as hypertensive disorders of pregnancy. This review aims to present a brief definition of hypertensive disorders of pregnancy and physiological maternal cardiovascular adaptations during pregnancy. We also detail how NO signalling is altered in the (a) systemic vasculature, (b) uterine artery/spiral arteries, (c) implantation and (d) placenta of hypertensive disorders during pregnancy. We conclude by summarizing the anti-hypertensive therapy of hypertensive disorders of pregnancy as a specific management strategy.
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Affiliation(s)
- Vanessa Dela Justina
- Graduate Program in Biological Sciences, Federal University of Goiás, Goiânia, Brazil
| | - Rinaldo Rodrigues Dos Passos Júnior
- Graduate Program in Biological Sciences, Federal University of Goiás, Goiânia, Brazil
- Institute of Health Sciences and Health, Universidad Federal De Mato Grosso, Barra do Garcas, Brazil
| | - Victor Vitorino Lima
- Institute of Health Sciences and Health, Universidad Federal De Mato Grosso, Barra do Garcas, Brazil
| | - Fernanda Regina Giachini
- Graduate Program in Biological Sciences, Federal University of Goiás, Goiânia, Brazil
- Institute of Health Sciences and Health, Universidad Federal De Mato Grosso, Barra do Garcas, Brazil
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20
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Thurstin AA, Egeli AN, Goldsmith EC, Spinale FG, LaVoie HA. Tissue inhibitor of metalloproteinase-4 deletion in mice impacts maternal cardiac function during pregnancy and postpartum. Am J Physiol Heart Circ Physiol 2023; 324:H85-H99. [PMID: 36459450 PMCID: PMC9799138 DOI: 10.1152/ajpheart.00408.2022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 11/22/2022] [Accepted: 11/29/2022] [Indexed: 12/03/2022]
Abstract
Reversible physiological cardiac hypertrophy of the maternal heart occurs during pregnancy and involves extracellular matrix (ECM) remodeling. Previous mouse studies revealed that changes in ECM molecules accompany functional changes in the left ventricle (LV) during late pregnancy and postpartum. We evaluated the effect of global Timp4 deletion in female mice on LV functional parameters and ECM molecules during pregnancy and the postpartum period. Heart weights normalized to tibia lengths were increased in Timp4 knockout (Timp4 KO) virgin, pregnant, and postpartum day 2 mice compared with wild types. Serial echocardiography performed on pregnancy days 10, 12, and 18 and postpartum days (ppds) 2, 7, 14, 21, and 28 revealed that both wild-type and Timp4 KO mice increased end systolic and end diastolic volumes (ESV, EDV) by mid to late pregnancy compared with virgins, with EDV changes persisting through the postpartum period. When compared with wild types, Timp4 KO mice exhibited higher ejection fractions in virgins, at pregnancy days 10 and 18 and ppd2 and ppd14. High-molecular weight forms of COL1A1 and COL3A1 proteins in LV were greater in Timp4 KO virgins, and COL1A1 was higher in late pregnancy and on ppd2 compared with wild types. With exceptions, Timp4 KO mice during late pregnancy and the early postpartum period were able to maintain stroke volume similar to wild-type mice through increased ejection fraction. Although TIMP4 deletion in females exhibited altered ECM molecules, it did not adversely affect cardiac function during first pregnancies and lactation.NEW & NOTEWORTHY Pregnancy and lactation increase volume load on the heart. Defects in cardiac remodeling during pregnancy and postpartum can result in peripartum cardiomyopathy. TIMPs participate in cardiac remodeling. The present study reports the cardiac function in Timp4 knockout adult female mice during pregnancy and lactation. Timp4 knockout females at many time points have higher ejection fraction to maintain stroke volume. Global deletion of Timp4 was not detrimental to maternal heart function during first pregnancies and lactation.
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Affiliation(s)
- Ashley A Thurstin
- Department of Cell Biology and Anatomy, University of South Carolina School of Medicine, Columbia, South Carolina
| | - Allison N Egeli
- Department of Cell Biology and Anatomy, University of South Carolina School of Medicine, Columbia, South Carolina
| | - Edie C Goldsmith
- Department of Cell Biology and Anatomy, University of South Carolina School of Medicine, Columbia, South Carolina
| | - Francis G Spinale
- Department of Cell Biology and Anatomy, University of South Carolina School of Medicine, Columbia, South Carolina
| | - Holly A LaVoie
- Department of Cell Biology and Anatomy, University of South Carolina School of Medicine, Columbia, South Carolina
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21
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Sławek-Szmyt S, Kawka-Paciorkowska K, Ciepłucha A, Lesiak M, Ropacka-Lesiak M. Preeclampsia and Fetal Growth Restriction as Risk Factors of Future Maternal Cardiovascular Disease-A Review. J Clin Med 2022; 11:6048. [PMID: 36294369 PMCID: PMC9605579 DOI: 10.3390/jcm11206048] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 09/26/2022] [Accepted: 10/10/2022] [Indexed: 12/01/2022] Open
Abstract
Cardiovascular diseases (CVDs) remain the leading cause of death in women worldwide. Although traditional risk factors increase later-life CVD, pregnancy-associated complications additionally influence future CVD risk in women. Adverse pregnancy outcomes, including preeclampsia and fetal growth restriction (FGR), are interrelated disorders caused by placental dysfunction, maternal cardiovascular maladaptation to pregnancy, and maternal abnormalities such as endothelial dysfunction, inflammation, hypercoagulability, and vasospasm. The pathophysiologic pathways of some pregnancy complications and CVDs might be linked. This review aimed to highlight the associations between specific adverse pregnancy outcomes and future CVD and emphasize the importance of considering pregnancy history in assessing a woman's CVD risk. Moreover, we wanted to underline the role of maternal cardiovascular maladaptation in the development of specific pregnancy complications such as FGR.
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Affiliation(s)
- Sylwia Sławek-Szmyt
- 1st Department of Cardiology, Poznan University of Medical Sciences, 61-848 Poznan, Poland
| | | | - Aleksandra Ciepłucha
- 1st Department of Cardiology, Poznan University of Medical Sciences, 61-848 Poznan, Poland
| | - Maciej Lesiak
- 1st Department of Cardiology, Poznan University of Medical Sciences, 61-848 Poznan, Poland
| | - Mariola Ropacka-Lesiak
- Department of Perinatology and Gynecology, Poznan University of Medical Sciences, 60-535 Poznan, Poland
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22
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Cauldwell M. Understanding the implications of hypertensive disorders in pregnancy in women with heart disease. Eur Heart J 2022; 43:3762-3764. [PMID: 35920159 DOI: 10.1093/eurheartj/ehac406] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Matthew Cauldwell
- Department of Obstetrics, Maternal Medicine Service, St George's Hospital, Blackshaw Road, London SW17 0QT, UK
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23
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Giorgione V, Thilaganathan B. Reply. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 60:296-297. [PMID: 35913383 DOI: 10.1002/uog.26026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Affiliation(s)
- V Giorgione
- Vascular Biology Research Center, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - B Thilaganathan
- Vascular Biology Research Center, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, London, UK
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24
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Gédéon T, Akl E, D'Souza R, Altit G, Rowe H, Flannery A, Siriki P, Bhatia K, Thorne S, Malhamé I. Acute Myocardial Infarction in Pregnancy. Curr Probl Cardiol 2022; 47:101327. [PMID: 35901856 DOI: 10.1016/j.cpcardiol.2022.101327] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 07/17/2022] [Indexed: 11/03/2022]
Abstract
Cardiovascular disease, and particularly ischemic heart disease, is a leading cause of maternal morbidity and mortality in high-income countries. The incidence of acute myocardial infarction (AMI) has been rising over the past two decades due to increasing maternal age and a higher prevalence of cardiovascular risk factors in the pregnant population. Causes of AMI in pregnancy are diverse and may require specific considerations for their diagnosis and management. In this narrative review, we provide an overview of physiologic changes, risk factors, and etiologies leading to AMI in pregnancy, as well as diagnostic tools, reperfusion strategies, and pharmacological treatments for this complex population. In addition, we outline considerations for labor and delivery planning and long-term follow-up of patients with AMI in pregnancy.
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Affiliation(s)
- Tara Gédéon
- Department of Medicine, McGill University Health Centre, Montreal, Canada
| | - Elie Akl
- Department of Medicine, McGill University Health Centre, Montreal, Canada
| | - Rohan D'Souza
- Department of Obstetrics and Gynaecology, McMaster University, Hamilton, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Gabriel Altit
- Department of Paediatrics, McGill University Health Centre, Montreal, Canada
| | - Hilary Rowe
- Department of Pharmacy, Nanaimo Regional General Hospital, Island Health, Nanaimo, Canada; Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada
| | - Alexandria Flannery
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Canada
| | | | - Kailash Bhatia
- Department of Anaesthesia, Manchester University Hospitals and St Mary's Hospital, University of Manchester, Manchester, United Kingdom
| | - Sara Thorne
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Isabelle Malhamé
- Department of Medicine, McGill University Health Centre, Montreal, Canada; Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Canada.
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25
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Reddy M, Palmer K, Rolnik DL, Wallace EM, Mol BW, Da Silva Costa F. Role of placental, fetal and maternal cardiovascular markers in predicting adverse outcome in women with suspected or confirmed pre-eclampsia. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 59:596-605. [PMID: 34985800 DOI: 10.1002/uog.24851] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 11/14/2021] [Accepted: 12/20/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To assess the performance of placental, fetal and maternal cardiovascular markers in the prediction of adverse perinatal and maternal outcomes in women with suspected or confirmed pre-eclampsia. METHODS This was a prospective prognostic accuracy study of women with suspected or confirmed pre-eclampsia who underwent a series of investigations to measure maternal hemodynamic indices, mean arterial pressure, augmentation index, ophthalmic artery peak systolic velocity (PSV) ratio, uterine artery pulsatility index (UtA-PI), fetal biometric and Doppler parameters, soluble fms-like tyrosine kinase-1 (sFlt-1) and placental growth factor (PlGF). The performance of these markers, individually or in combination, in predicting adverse perinatal and maternal outcomes was then assessed using receiver-operating-characteristics (ROC)-curve analysis. Adverse maternal outcome was defined as one or more of severe hypertension, admission to the intensive care unit, eclampsia, placental abruption, HELLP syndrome, disseminated intravascular coagulation, platelets < 100 × 109 /L, creatinine > 90 μmol/L and alanine aminotransferase > 100 U/L. Adverse perinatal outcome was defined as one or more of preterm birth at or before 34 + 0 weeks, neonatal intensive care unit admission for > 48 h, respiratory distress syndrome, intraventricular hemorrhage, hypoxic ischemic encephalopathy, necrotizing enterocolitis, retinopathy of prematurity and confirmed fetal infection. RESULTS We recruited 126 women with suspected (n = 31) or confirmed (n = 95) pre-eclampsia at a median gestational age of 33.9 weeks (interquartile range, 30.9-36.3 weeks). Pregnancies with adverse perinatal outcome compared to those without had a higher median UtA-PI (1.3 vs 0.8; P < 0.001), ophthalmic artery PSV ratio (0.8 vs 0.7; P = 0.01) and umbilical artery PI percentile (82.0 vs 68.5; P < 0.01) and lower median estimated fetal weight percentile (4.0 vs 43.0; P < 0.001), abdominal circumference percentile (4.0 vs 63.0; P < 0.001), middle cerebral artery PI percentile (28.0 vs 58.5; P < 0.001) and cerebroplacental ratio percentile (18.0 vs 46.5; P < 0.001). Pregnancies with adverse perinatal outcome also had a higher median sFlt-1 (8208.0 pg/mL vs 4508.0 pg/mL; P < 0.001), lower PlGF (27.2 pg/mL vs 76.3 pg/mL; P < 0.001) and a higher sFlt-1/PlGF ratio (445.4 vs 74.4; P < 0.001). The best performing individual marker for predicting adverse perinatal outcome was the sFlt-1/PlGF ratio (area under the ROC curve (AUC), 0.87 (95% CI, 0.81-0.93)), followed by estimated fetal weight (AUC, 0.81 (95% CI, 0.73-0.89)). Women who experienced adverse maternal outcome had a higher median sFlt-1 level (7471.0 pg/mL vs 5131.0 pg/mL; P < 0.001) and sFlt-1/PlGF ratio (204.3 vs 93.3; P < 0.001) and a lower PlGF level (37.0 pg/mL vs 66.1 pg/mL; P = 0.01) and estimated fetal weight percentile (16.5 vs 37.0; P = 0.04). All markers performed poorly in predicting adverse maternal outcome, with sFlt-1 (AUC, 0.69 (95% CI, 0.60-0.79)) and sFlt-1/PlGF ratio (AUC, 0.69 (95% CI, 0.59-0.78)) demonstrating the best individual performance. The addition of cardiovascular, fetal or other placental indices to the sFlt-1/PlGF ratio did not improve the prediction of adverse maternal or perinatal outcomes. CONCLUSIONS The sFlt-1/PlGF ratio performs well in predicting adverse perinatal outcomes but is a poor predictor of adverse maternal outcomes in women with suspected or diagnosed pre-eclampsia. The addition of cardiovascular or fetal indices to the model is unlikely to improve the prognostic performance of the sFlt-1/PlGF ratio. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- M Reddy
- Department of Obstetrics and Gynaecology, School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
- Monash Women's, Monash Health, Clayton, Victoria, Australia
| | - K Palmer
- Department of Obstetrics and Gynaecology, School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
- Monash Women's, Monash Health, Clayton, Victoria, Australia
| | - D L Rolnik
- Department of Obstetrics and Gynaecology, School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
- Monash Women's, Monash Health, Clayton, Victoria, Australia
| | - E M Wallace
- Department of Obstetrics and Gynaecology, School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
| | - B W Mol
- Department of Obstetrics and Gynaecology, School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
- Aberdeen Centre for Women's Health Research, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - F Da Silva Costa
- Department of Obstetrics and Gynaecology, School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
- Maternal Fetal Medicine Unit, Gold Coast University Hospital and School of Medicine, Griffith University, Gold Coast, Queensland, Australia
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Giorgione V, Melchiorre K, O'Driscoll J, Khalil A, Sharma R, Thilaganathan B. Maternal echocardiographic changes in twin pregnancies with and without pre-eclampsia. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 59:619-626. [PMID: 35000243 DOI: 10.1002/uog.24852] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 11/23/2021] [Accepted: 12/22/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVE Twin pregnancies are at increased risk of developing hypertensive disorders of pregnancy (HDP) compared with singleton pregnancies, resulting in a substantially higher rate of maternal and perinatal complications. The strain caused by twin pregnancy on the maternal cardiovascular system has not been studied extensively. The objective of this study was to evaluate the changes in maternal cardiac morphology and diastolic function in a cohort of women with normotensive and those with hypertensive twin pregnancies. METHODS This was a cross-sectional study conducted at a tertiary referral university center. Women with singleton or twin pregnancy were enrolled prospectively to undergo maternal transthoracic echocardiography throughout pregnancy. Multiples of the median (MoM) were calculated for each index using a reference group of uncomplicated singleton pregnancies (n = 411) in order to adjust for changes associated with gestational age. Cardiac findings were indexed for body surface area and compared among normotensive twin pregnancies, singleton pregnancies complicated by HDP and twin pregnancies complicated by HDP. RESULTS The total cohort included 119 HDP singleton pregnancies, 52 normotensive twin pregnancies and 24 HDP twin pregnancies. Left ventricular mass index (LVMi) MoM (median (interquartile range)) did not differ between singleton pregnancies complicated by HDP and normotensive twin pregnancies, but was significantly higher in HDP twin compared with HDP singleton pregnancies (1.31 (1.08-1.53) vs 1.17 (0.98-1.35), P = 0.032). Two diastolic indices, left atrial volume index MoM (1.12 (0.66-1.38) vs 0.65 (0.55-0.84), P = 0.003) and E/e' MoM (1.29 (1.09-1.54) vs 0.99 (0.99-1.02), P = 0.036), were significantly higher in HDP twin compared with normotensive twin pregnancies. In normotensive twin compared with HDP singleton pregnancies, stroke volume index (SVi) MoM was higher (1.20 (1.03-1.36) vs 1.00 (0.81-1.15), P = 0.004) and total vascular resistance index (TVRi) was lower (0.73 (0.70-0.86) vs 1.29 (1.04-1.56), P < 0.0001). In contrast, SVi MoM was lower (1.10 (1.02-1.35) vs 1.20 (1.03-1.36), P = 0.018) and TVRi was higher (1.00 (0.88-1.31) vs 0.73 (0.70-0.86), P = 0.029) in HDP twin compared with normotensive twin pregnancies. CONCLUSION The maternal cardiovascular system is altered severely in twin pregnancy with or without HDP. Despite the low total vascular resistance, cardiac changes in normotensive twin pregnancies are comparable to those seen in singleton pregnancies complicated by HDP, reflecting the high cardiovascular demand imposed by twin pregnancy. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- V Giorgione
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - K Melchiorre
- Department of Obstetrics and Gynaecology, Spirito Santo Tertiary Level Hospital of Pescara, Pescara, Italy
| | - J O'Driscoll
- Department of Cardiology, St George's University Hospitals NHS Foundation Trust, London, UK
- School of Psychology and Life Sciences, Canterbury Christ Church University, Canterbury, UK
| | - A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - R Sharma
- Department of Cardiology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - B Thilaganathan
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
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Toncelli L, Pasquini L, Masini G, Orlandi M, Paci G, Mecacci F, Pedrizzetti G, Galanti G. Difference in cardiac remodeling between female athletes and pregnant women: a case control study. Cardiovasc Ultrasound 2022; 20:10. [PMID: 35418063 PMCID: PMC9006435 DOI: 10.1186/s12947-022-00280-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 03/25/2022] [Indexed: 12/05/2022] Open
Abstract
OBJECTIVES The aim of this study was to detect possible differences in reversible cardiac remodeling occurring in sport training and twin pregnancy. BACKGROUND cardiac remodeling occurs in athletes and pregnant women due to training and fetal requirements, respectively. These changes could be apparently similar. METHODS 21 female elite athletes (23.2 ± 5.3 years), 25 women with twin pregnancies (35.4 ± 5.7 years) and 25 healthy competitive female athletes (controls), age-matched with pregnant women (34.9 ± 7.9 years), were enrolled. This latter group was included to minimize the effect of age on cardiac remodeling. All women evaluated through anamnestic collection, physical examination, 12 leads ECG, standard echocardiogram and strain analysis. Sphericity (SI) and apical conicity (ACI) indexes were also calculated. RESULTS Pregnant women showed higher LA dimension (p < 0.001) compared to both groups of athletes. LV e RV GLS were significantly different in pregnant women compared to female athletes (p = 0.02 and 0.03, respectively). RV GLS was also different between pregnant women and controls (p = 0.02). Pregnant women showed significantly higher S' wave compared to female athletes (p = 0.02) but not controls. Parameters of diastolic function were significantly higher in athletes (p = 0.08 for IVRT and p < 0.001 for E/A,). SI was lower in athletes in both diastole (p = 0.01) and systole (p < 0.001), while ACIs was lower in pregnant women (p = 0.04). CONCLUSIONS Cardiac remodeling of athletes and pregnant women could be similar at first sight but different in LV shape and in GLS, highlighting a profound difference in longitudinal deformation between athletes and pregnant women. This difference seems not to be related with age. These findings suggest that an initial maternal cardiovascular maladaptation could occur in the third trimester of twin pregnancies.
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Affiliation(s)
- Loira Toncelli
- Sport and Exercise Medicine Department of University of Florence, via delle Oblate 4, 50100, Florence, FI, Italy
| | - Lucia Pasquini
- Fetal Medicine Unit, Department for Women and Children Health, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Giulia Masini
- Fetal Medicine Unit, Department for Women and Children Health, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Melissa Orlandi
- Sport and Exercise Medicine Department of University of Florence, via delle Oblate 4, 50100, Florence, FI, Italy
| | - Gabriele Paci
- Sport and Exercise Medicine Department of University of Florence, via delle Oblate 4, 50100, Florence, FI, Italy
| | - Federico Mecacci
- Fetal Medicine Unit, Department for Women and Children Health, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Gianni Pedrizzetti
- Architectural and Engineering Department of University of Trieste, Trieste, Italy
| | - Giorgio Galanti
- Sport and Exercise Medicine Department of University of Florence, via delle Oblate 4, 50100, Florence, FI, Italy.
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Noninvasive Cardiac Imaging in Formerly Preeclamptic Women for Early Detection of Subclinical Myocardial Abnormalities: A 2022 Update. Biomolecules 2022; 12:biom12030415. [PMID: 35327607 PMCID: PMC8946283 DOI: 10.3390/biom12030415] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/02/2022] [Accepted: 03/03/2022] [Indexed: 02/04/2023] Open
Abstract
Preeclampsia is a maternal hypertensive disease, complicating 2–8% of all pregnancies. It has been linked to a 2–7-fold increased risk for the development of cardiovascular disease, including heart failure, later in life. A total of 40% of formerly preeclamptic women develop preclinical heart failure, which may further deteriorate into clinical heart failure. Noninvasive cardiac imaging could assist in the early detection of myocardial abnormalities, especially in the preclinical stage, when these changes are likely to be reversible. Moreover, imaging studies can improve our insights into the relationship between preeclampsia and heart failure and can be used for monitoring. Cardiac ultrasound is used to assess quantitative changes, including the left ventricular cavity volume and wall thickness, myocardial mass, systolic and diastolic function, and strain. Cardiac magnetic resonance imaging may be of additional diagnostic value to assess diffuse and focal fibrosis and perfusion. After preeclampsia, sustained elevated myocardial mass along with reduced myocardial circumferential and longitudinal strain and decreased diastolic function is reported. These findings are consistent with the early phases of heart failure, referred to as preclinical (asymptomatic) or B-stage heart failure. In this review, we will provide an up-to-date overview of the potential of cardiac magnetic resonance imaging and echocardiography in identifying formerly preeclamptic women who are at high risk for developing heart failure. The potential contribution to early cardiac screening of women with a history of preeclampsia and the pros and cons of these imaging modalities are outlined. Finally, recommendations for future research are presented.
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Giorgione V, O'Driscoll J, Coutinho CM, Di Fabrizio C, Sharma R, Khalil A, Thilaganathan B. Peripartum echocardiographic changes in women with hypertensive disorders of pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 59:365-370. [PMID: 34309939 DOI: 10.1002/uog.23745] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 07/18/2021] [Accepted: 07/19/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE Hypertensive disorders of pregnancy (HDP) are associated with significant myocardial dysfunction on echocardiography. The impact of hemodynamic changes related to volume redistribution following delivery on myocardial function in women with HDP has not been evaluated systematically. The aim of this study was to compare echocardiographic findings immediately before and after delivery in women with HDP. METHODS This was a prospective longitudinal study including 30 women with a diagnosis of HDP who underwent two consecutive transthoracic echocardiographic (TTE) examinations, before delivery and in the early postpartum period. Paired comparisons of the findings from the two assessments were performed. RESULTS Left-ventricular (LV) concentric remodeling or hypertrophy was detected in 21 (70%) patients. There was no significant difference in cardiac morphology indices such as LV mass index (78.9 ± 16.3 g/m2 vs 77.9 ± 15.4 g/m2 ; P = 0.611) or relative wall thickness (0.45 ± 0.1 vs 0.44 ± 0.1; P = 0.453) before vs after delivery. LV diastolic function did not demonstrate any peripartum variation, with similar left-atrial volume (52.4 ± 15.3 mL vs 51.0 ± 15.6 mL; P = 0.433), lateral E' (0.12 ± 0.03 m/s vs 0.12 ± 0.03 m/s; P = 0.307) and E/E' ratio (7.9 ± 2.2 vs 7.9 ± 1.7; P = 0.934) before vs after delivery. Systolic function indices, such as LV ejection fraction (57.5 ± 3.4% vs 56.4 ± 2.1%; P = 0.295) and global longitudinal strain (-15.3 ± 2.6% vs -15.1 ± 3.1%; P = 0.582), also remained unchanged between before vs after delivery. CONCLUSIONS Maternal hemodynamic changes associated with delivery did not influence significantly peripartum TTE indices in women with HDP. Suboptimal maternal echocardiographic findings in HDP are likely to be the consequence of chronic pregnancy cardiovascular load changes or pre-existing maternal cardiovascular impairment. Severity and persistence of myocardial dysfunction in the postpartum period may be related to the long-term maternal cardiovascular disease legacy of HDP. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- V Giorgione
- Vascular Biology Research Center, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - J O'Driscoll
- Department of Cardiology, St George's University Hospitals NHS Foundation Trust, London, UK
- School of Psychology and Life Sciences, Canterbury Christ Church University, Canterbury, UK
| | - C M Coutinho
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Department of Gynecology and Obstetrics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - C Di Fabrizio
- Vascular Biology Research Center, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - R Sharma
- Department of Cardiology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - A Khalil
- Vascular Biology Research Center, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - B Thilaganathan
- Vascular Biology Research Center, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
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Abstract
Peripartum cardiomyopathy (PPCM) is a potentially fatal form of idiopathic heart failure with variable prevalence across different countries and ethnic groups. The cause of PPCM is unclear, but environmental and genetic factors and pregnancy-associated conditions such as pre-eclampsia can contribute to the development of PPCM. Furthermore, animal studies have shown that impaired vascular and metabolic function might be central to the development of PPCM. A better understanding of the pathogenic mechanisms involved in the development of PPCM is necessary to establish new therapies that can improve the outcomes of patients with PPCM. Pregnancy hormones tightly regulate a plethora of maternal adaptive responses, including haemodynamic, structural and metabolic changes in the cardiovascular system. In patients with PPCM, the peripartum period is associated with profound and rapid hormonal fluctuations that result in a brief period of disrupted cardiovascular (metabolic) homeostasis prone to secondary perturbations. In this Review, we discuss the latest studies on the potential pathophysiological mechanisms of and risk factors for PPCM, with a focus on maternal cardiovascular changes associated with pregnancy. We provide an updated framework to further our understanding of PPCM pathogenesis, which might lead to an improvement in disease definition.
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Comunale G, Susin FM, Mynard JP. Ventricular wall stress and wall shear stress homeostasis predicts cardiac remodeling during pregnancy: A modeling study. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2022; 38:e3536. [PMID: 34599558 PMCID: PMC9285413 DOI: 10.1002/cnm.3536] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 09/29/2021] [Indexed: 06/13/2023]
Abstract
Pregnancy is a unique and dynamic process characterized by significant changes in the maternal cardiovascular system that are required to satisfy the increased maternal and fetal metabolic demands. Profound structural and hemodynamic adaptations occur during healthy pregnancy that allows the mother to maintain healthy hemodynamics and provide an adequate uteroplacental blood circulation to ensure physiological fetal development. Investigating these adaptations is crucial for understanding the physiology of pregnancy and may provide important insights for the management of high-risk pregnancies. However, no previous modeling studies have investigated the maternal cardiac structural changes that occur during gestation. This study, therefore, had two aims. The first was to develop a lumped parameter model of the whole maternal circulation that is suitable for studying global hemodynamics and cardiac function at different stages of gestation. The second was to test the hypothesis that myofiber stress and wall shear stress homeostasis principles can be used to predict cardiac remodeling that occurs during normal pregnancy. Hemodynamics and cardiac variables predicted from simulations with and without controlled cardiac remodeling algorithms were compared and evaluated with reference clinical data. While both models reproduced the hemodynamic variations that arise in pregnancy, importantly, we show that the structural changes that occur with pregnancy could be predicted by assuming invariant homeostatic "target" values of myocardial wall stress and chamber wall shear stress.
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Affiliation(s)
- Giulia Comunale
- Cardiovascular Fluid Dynamics Laboratory HER, Department of Civil, Environmental and Architectural EngineeringUniversity of PadovaPadovaItaly
- Heart ResearchMurdoch Children's Research InstituteParkvilleVictoriaAustralia
| | - Francesca M. Susin
- Cardiovascular Fluid Dynamics Laboratory HER, Department of Civil, Environmental and Architectural EngineeringUniversity of PadovaPadovaItaly
| | - Jonathan P. Mynard
- Heart ResearchMurdoch Children's Research InstituteParkvilleVictoriaAustralia
- Department of PediatricsUniversity of MelbourneParkvilleVictoriaAustralia
- Department of Biomedical EngineeringUniversity of MelbourneParkvilleVictoriaAustralia
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Incidence of essential hypertension but not echocardiographic abnormalities at four years with a history of preeclampsia with severe features. Pregnancy Hypertens 2021; 25:185-190. [PMID: 34182431 PMCID: PMC8828283 DOI: 10.1016/j.preghy.2021.06.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 05/29/2021] [Accepted: 06/08/2021] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Women with preeclampsia are more likely to have abnormal echocardiographic parameters at the time of diagnosis and are more likely to have hypertension and other cardiovascular diseases (CVD) later in life. Screening for future CVD in preeclamptic women would assist in appropriately risk stratifying and identifying high risk women for preventive management; however, the timing of screening and the screening factors are unknown. OBJECTIVE The objectives of this project are to 1) assess incidence of essential hypertension 4 years after pregnancy in preeclampsia with severe features (PEC) 2) identify predictive echocardiographic variables at the time of PEC diagnosis and 3) assess the rate of echocardiographic abnormalities 4 years after developing PEC. STUDY DESIGN This is a prospective longitudinal study observing the incidence of essential hypertension in women within 4 years of a pregnancy complicated by PEC. We further looked at echocardiographic variables at the time of PEC diagnosis and at 4 years after PEC pregnancy in women with and without subsequent incident essential hypertension. The primary outcome measure is the incidence of essential hypertension within 4 years of PEC pregnancy, defined as a systolic blood pressure ≥ 130 mmHg or a diastolic blood pressure ≥ 80 mmHg. Secondary imaging outcomes include the persistence of abnormal echocardiographic parameters. Clinical secondary outcomes are new diagnoses of severe CVD, including coronary artery disease, stroke, arrhythmia, heart failure, or inpatient hospital admission for CVD. RESULTS Of the 33 enrolled women with PEC, 48% (16/33) developed incident essential hypertension within 4 years of delivery. These women had thicker left ventricular posterior walls on their initial antenatal echocardiogram when compared to the 52% (17/33) who did not develop hypertension (1.0 cm [0.9-1.1 cm] vs 0.9 cm [0.7-0.9 cm]. p < 0.016). However, these abnormal echocardiographic variables resolved in the 16 women who underwent 4-year follow-up echocardiography. CONCLUSION Women who develop PEC have a high incidence of essential hypertension within 4 years of delivery. The group who develops essential hypertension are more likely to have evidence of adverse cardiac remodeling at the time of PEC diagnosis; however, neither group have cardiac echocardiographic abnormalities 4 years postpartum. Because this is a small study, larger long-term cohort studies are needed to confirm these echocardiographic and clinical findings.
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Adaptation of left ventricular diastolic function to pregnancy: a systematic review and meta-analysis. J Hypertens 2021; 39:1934-1941. [PMID: 34001811 PMCID: PMC8452327 DOI: 10.1097/hjh.0000000000002886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Objective: To meta-analytically determine the adaptation of left ventricular diastolic function (LVDF)-indices to singleton normotensive pregnancies. Methods: Literature was retrieved from PubMed and Embase. We included studies that reported a nonpregnant reference measurement and LVDF indices (mitral inflow signals, left atrial volume and tissue Doppler measurements). Mean differences between pregnant and reference measurements and weighted means of absolute values were calculated using a random-effects model. Results: We included 34 eligible studies. Normotensive pregnancies were characterized by an initially larger increase in the passive left ventricular filling (E-wave peak velocity, 13%) compared to active left ventricular filling during diastole (A-wave peak velocity, 6%) resulting in a 16% increase of the E/A ratio in the first trimester. The E/A ratio progressively decreased during advancing gestation to −18% at term, resulting from stabilizing E-wave peak velocity and increased A-wave peak velocity. The E/e′ ratio was increased between 22 and 35 weeks (a maximal increase of 13%) in normotensive pregnancy. Left atrial volume (LAV) progressively increased from 15 weeks onwards with a maximal increase of 30% between 36 and 41 weeks. Conclusion: LVDF in normotensive pregnancy was improved in the first trimester after which LVDF progressively worsened. Large-scale studies in normotensive and hypertensive complicated pregnancies are needed for a more precise insight into LVDF changes during pregnancy.
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Bello NA, Bairey Merz CN, Brown H, Davis MB, Dickert NW, El Hajj SC, Giullian C, Quesada O, Park K, Sanghani RM, Shaw L, Volgman AS, Wenger NK, Williams D, Pepine CJ, Lindley KJ. Diagnostic Cardiovascular Imaging and Therapeutic Strategies in Pregnancy: JACC Focus Seminar 4/5. J Am Coll Cardiol 2021; 77:1813-1822. [PMID: 33832607 DOI: 10.1016/j.jacc.2021.01.056] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/19/2021] [Accepted: 01/29/2021] [Indexed: 12/21/2022]
Abstract
The prevalence of cardiovascular disease (CVD) in pregnancy, both diagnosed and previously unknown, is rising, and CVD is a leading cause of maternal morbidity and mortality. Historically, women of child-bearing potential have been underrepresented in research, leading to lasting knowledge gaps in the cardiovascular care of pregnant and lactating women. Despite these limitations, clinicians should be familiar with the safety of frequently used diagnostic and therapeutic interventions to adequately care for this at-risk population. This review, the fourth of a 5-part series, provides evidence-based recommendations regarding the use of common cardiovascular diagnostic tests and medications in pregnant and lactating women.
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Affiliation(s)
- Natalie A Bello
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA.
| | - C Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, California, USA
| | - Haywood Brown
- Department of Obstetrics and Gynecology, University of South Florida, Tampa, Florida, USA
| | - Melinda B Davis
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Neal W Dickert
- Emory University School of Medicine, Atlanta, Georgia, USA; Emory Heart and Vascular Center, Atlanta, Georgia, USA
| | - Stephanie C El Hajj
- ProMedica Physicians Cardiology, Toledo, Ohio, USA; Mayo Clinic, Rochester, Minnesota, USA
| | | | - Odayme Quesada
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, California, USA; The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, Cincinnati, Ohio, USA
| | - Ki Park
- Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Rupa M Sanghani
- Division of Cardiology, Rush University Medical Center, Chicago, Illinois, USA
| | - Leslee Shaw
- Department of Radiology and Medicine, New York-Presbyterian Hospital and Weill Cornell Medicine, New York, New York, USA
| | | | - Nanette K Wenger
- Emory University School of Medicine, Emory Heart and Vascular Center, Emory Women's Heart Center, Atlanta, Georgia, USA
| | - Dominique Williams
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Carl J Pepine
- Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Kathryn J Lindley
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
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Mulder EG, de Haas S, Mohseni Z, Schartmann N, Abo Hasson F, Alsadah F, van Kuijk S, van Drongelen J, Spaanderman M, Ghossein-Doha C. Cardiac output and peripheral vascular resistance during normotensive and hypertensive pregnancy - a systematic review and meta-analysis. BJOG 2021; 129:696-707. [PMID: 33630403 PMCID: PMC9291763 DOI: 10.1111/1471-0528.16678] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND In-depth insight into haemodynamic changes during normotensive pregnancy may help identify women at risk for gestational hypertensive complications. OBJECTIVES To determine the magnitude of changes in cardiac output and its determinants stroke volume and heart rate, and total peripheral vascular resistance during singleton normotensive and hypertensive pregnancies. SEARCH STRATEGY PubMed (NCBI) and Embase (Ovid) databases were searched from their inception up to November 2019. SELECTION CRITERIA Studies reporting original measurements of haemodynamic parameters during pregnancy together with a non-pregnant reference measurement. Studies including women using antihypertensive medication were excluded. DATA COLLECTION AND ANALYSIS Pooled mean differences between pregnant and non-pregnant women, and absolute values of haemodynamic parameters were calculated for predefined gestational intervals using a random-effects model in normotensive and hypertensive pregnancy. Meta-regression analysis was used to analyse group differences in adjustments and absolute values during pregnancy. MAIN RESULTS In normotensive pregnancies, cardiac output increased from the first weeks on, reaching its highest level early in the third trimester (mean difference, 1.41 l·min1 ; 95% CI 1.18-1.63 l·min-1 ). In parallel, vascular resistance decreased progressively until its nadir in the early third trimester (mean difference, -331 dyn·sec-1 ·cm-5 ; 95% CI -384 to -277 dyn·sec-1 ·cm-5 ) and then increased slightly at term. In hypertensive pregnancies, the initial cardiac output increase was higher and vascular resistance did not change throughout gestation compared with reference values. CONCLUSIONS Hemodynamic changes in women who eventually develop hypertensive complications are substantially different. Serial monitoring and plotting against developed normograms can identify women at risk and may allow timely intervention. TWEETABLE ABSTRACT Monitoring haemodynamic changes in pregnancy helps identify women at risk for hypertensive complications.
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Affiliation(s)
- E G Mulder
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - S de Haas
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Z Mohseni
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - N Schartmann
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - F Abo Hasson
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - F Alsadah
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Smj van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - J van Drongelen
- Department of Obstetrics and Gynaecology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Mea Spaanderman
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, Maastricht, The Netherlands.,Department of Obstetrics and Gynaecology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - C Ghossein-Doha
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, Maastricht, The Netherlands.,Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
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Yang Y, Kurian J, Schena G, Johnson J, Kubo H, Travers JG, Kang C, Lucchese AM, Eaton DM, Lv M, Li N, Leynes LG, Yu D, Yang F, McKinsey TA, Kishore R, Khan M, Mohsin S, Houser SR. Cardiac Remodeling During Pregnancy With Metabolic Syndrome: Prologue of Pathological Remodeling. Circulation 2021; 143:699-712. [PMID: 33587660 PMCID: PMC7888689 DOI: 10.1161/circulationaha.120.051264] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 12/30/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND The heart undergoes physiological hypertrophy during pregnancy in healthy individuals. Metabolic syndrome (MetS) is now prevalent in women of child-bearing age and might add risks of adverse cardiovascular events during pregnancy. The present study asks if cardiac remodeling during pregnancy in obese individuals with MetS is abnormal and whether this predisposes them to a higher risk for cardiovascular disorders. METHODS The idea that MetS induces pathological cardiac remodeling during pregnancy was studied in a long-term (15 weeks) Western diet-feeding animal model that recapitulated features of human MetS. Pregnant female mice with Western diet (45% kcal fat)-induced MetS were compared with pregnant and nonpregnant females fed a control diet (10% kcal fat). RESULTS Pregnant mice fed a Western diet had increased heart mass and exhibited key features of pathological hypertrophy, including fibrosis and upregulation of fetal genes associated with pathological hypertrophy. Hearts from pregnant animals with WD-induced MetS had a distinct gene expression profile that could underlie their pathological remodeling. Concurrently, pregnant female mice with MetS showed more severe cardiac hypertrophy and exacerbated cardiac dysfunction when challenged with angiotensin II/phenylephrine infusion after delivery. CONCLUSIONS These results suggest that preexisting MetS could disrupt physiological hypertrophy during pregnancy to produce pathological cardiac remodeling that could predispose the heart to chronic disorders.
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Affiliation(s)
- Yijun Yang
- Independence Blue Cross Cardiovascular Research Center and Department of Pharmacology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, United States
| | - Justin Kurian
- Center for Metabolic Disease and Department of Physiology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, United States
| | - Giana Schena
- Independence Blue Cross Cardiovascular Research Center and Department of Pharmacology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, United States
| | - Jaslyn Johnson
- Independence Blue Cross Cardiovascular Research Center and Department of Pharmacology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, United States
| | - Hajime Kubo
- Independence Blue Cross Cardiovascular Research Center and Department of Pharmacology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, United States
| | - Joshua G. Travers
- Department of Medicine, Division of Cardiology, and Consortium for Fibrosis Research & Translation, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Chunya Kang
- Medical University of Lublin, Lublin, Poland
| | - Anna Maria Lucchese
- Center for Translational Medicine, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, United States
| | - Deborah M. Eaton
- Independence Blue Cross Cardiovascular Research Center and Department of Pharmacology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, United States
| | - Maoting Lv
- Second Ultrasound Department, Cangzhou Central Hospital, Hebei, China
| | - Na Li
- Second Department of Obstetrics, Cangzhou Central Hospital, Hebei, China
| | - Lorianna G. Leynes
- Lewis Katz School of Medicine at Temple University, Philadelphia, PA, United States
| | - Daohai Yu
- Department of Clinical Sciences, Lewis Katz School of Medicine at Temple University, PA, United States
| | - Fengzhen Yang
- Second Department of Obstetrics, Cangzhou Central Hospital, Hebei, China
| | - Timothy A. McKinsey
- Department of Medicine, Division of Cardiology, and Consortium for Fibrosis Research & Translation, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Raj Kishore
- Center for Translational Medicine, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, United States
| | - Mohsin Khan
- Center for Metabolic Disease and Department of Physiology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, United States
| | - Sadia Mohsin
- Independence Blue Cross Cardiovascular Research Center and Department of Pharmacology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, United States
| | - Steven R. Houser
- Independence Blue Cross Cardiovascular Research Center and Department of Pharmacology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, United States
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Meah VL, Kimber ML, Khurana R, Howse R, Hornberger LK, Steinback CD, Davenport MH. Cardioautonomic control in healthy singleton and twin pregnancies. J Appl Physiol (1985) 2020; 130:923-932. [PMID: 33356983 DOI: 10.1152/japplphysiol.00707.2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
In conjunction with significant cardiovascular adaptation, changes in cardioautonomic balance, specifically greater sympathetic activation and vagal withdrawal, are considered normal adaptations to healthy singleton pregnancy. Cardiovascular adaptation to twin pregnancy is more profound than that of singleton pregnancies; however, the changes in cardioautonomic control during multifetal gestation are unknown. To address this gap, beat-by-beat blood pressure (photoplethysmography) and heart rate (lead II electrocardiogram) were measured continuously in 25 twin pregnancies and 25 singleton pregnancies (matched for age, prepregnancy body mass index, and gestational age) during 10 min of rest. Data extracted from a 3- to 5-min period were used to analyze heart rate variability (HRV), blood pressure variability (BPV), cardiovagal baroreflex gain, and cardiac intervals as indicators of cardioautonomic control. Independent t tests were used to determine statistical differences between groups (α = 0.05), and the false rate discovery was determined to adjust for multiple comparisons. Resting heart rate was greater in twin compared with singleton pregnancies (91 ± 10 vs. 81 ± 10 beats/min; P = 0.001), but blood pressure was not different. Individuals with twin pregnancies had lower HRV, evidenced by lower standard deviation of R-R intervals (32 ± 11 vs. 47 ± 18 ms; P = 0.001), total power (1,035 ± 810 vs. 1,945 ± 1,570 ms2; P = 0.004), and high frequency power (224 ± 262 vs. 810 ± 806 ms2; P < 0.001) compared with singleton pregnancies. There were no differences in cardiac intervals, BPV, and cardiovagal baroreflex gain between groups. Our findings suggest that individuals with twin pregnancies have greater sympathetic and lower parasympathetic contributions to heart rate and that cardiac, but not vascular, autonomic control is impacted during twin compared with singleton pregnancy.NEW & NOTEWORTHY Individuals with healthy twin pregnancies had lower overall heart rate variability compared with those with singleton pregnancies at similar gestational ages. These results suggest a greater sympathetic and reduced parasympathetic contribution to cardiac control in twin pregnancies. Baseline heart rate was elevated, while arterial pressure and spontaneous cardiovagal baroreflex gain were not different between groups. This was result of the upward resetting of the cardiovagal baroreflex during healthy twin pregnancy, thus maintaining arterial pressure.
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Affiliation(s)
- Victoria L Meah
- Physical Activity and Diabetes Laboratory, Faculty of Kinesiology, Sport and Recreation, Women and Children's Health Research Institute, Alberta Diabetes Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Miranda L Kimber
- Physical Activity and Diabetes Laboratory, Faculty of Kinesiology, Sport and Recreation, Women and Children's Health Research Institute, Alberta Diabetes Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Rshmi Khurana
- Departments of Medicine and Obstetrics and Gynecology, Women and Children's Health Research Institute, University of Alberta, Edmonton, Alberta, Canada
| | | | - Lisa K Hornberger
- Division of Cardiology, Department of Pediatrics, Fetal and Neonatal Cardiology Program, Women's and Children Health Research Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Craig D Steinback
- Physical Activity and Diabetes Laboratory, Faculty of Kinesiology, Sport and Recreation, Women and Children's Health Research Institute, Alberta Diabetes Institute, University of Alberta, Edmonton, Alberta, Canada.,Neurovascular Health Laboratory, Faculty of Kinesiology, Sport, and Recreation, University of Alberta, Edmonton, Alberta, Canada
| | - Margie H Davenport
- Physical Activity and Diabetes Laboratory, Faculty of Kinesiology, Sport and Recreation, Women and Children's Health Research Institute, Alberta Diabetes Institute, University of Alberta, Edmonton, Alberta, Canada
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Ormesher L, Higson S, Luckie M, Roberts SA, Glossop H, Trafford A, Cottrell E, Johnstone ED, Myers JE. Postnatal Enalapril to Improve Cardiovascular Function Following Preterm Preeclampsia (PICk-UP):: A Randomized Double-Blind Placebo-Controlled Feasibility Trial. Hypertension 2020; 76:1828-1837. [PMID: 33012200 PMCID: PMC7610547 DOI: 10.1161/hypertensionaha.120.15875] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 08/19/2020] [Indexed: 12/16/2022]
Abstract
Hypertensive disease in pregnancy is associated with future cardiovascular disease and, therefore, provides an opportunity to identify women who could benefit from targeted interventions aimed at reducing cardiovascular morbidity. This study focused on the highest-risk group, women with preterm preeclampsia, who have an 8-fold risk of death from future cardiovascular disease. We performed a single-center feasibility randomized controlled trial of 6 months' treatment with enalapril to improve postnatal cardiovascular function. Echocardiography and hemodynamic measurements were performed at baseline (<3 days), 6 weeks, and 6 months postdelivery on 60 women. At randomization, 88% of women had diastolic dysfunction, and 68% had concentric remodeling/hypertrophy. No difference was seen in total vascular resistance (P=0.59) or systolic function (global longitudinal strain: P=0.14) between groups at 6 months. However, women treated with enalapril had echocardiographic measurements consistent with improved diastolic function (E/E'[the ratio of early mitral inflow velocity and early mitral annular diastolic velocity]: P=0.04) and left ventricular remodeling (relative wall thickness: P=0.01; left ventricular mass index: P=0.03) at 6 months, compared with placebo. Urinary enalapril was detectable in 85% and 63% of women in the enalapril arm at 6 weeks and 6 months, respectively. All women responded positively to taking enalapril in the future. Our study confirmed acceptability and feasibility of the study protocol with a recruitment to completion rate of 2.2 women per month. Importantly, postnatal enalapril treatment was associated with improved echocardiographic measurements; these early improvements have the potential to reduce long-term cardiovascular disease risk. A definitive, multicenter randomized controlled trial is now required to confirm these findings. Registration- URL: https://www.clinicaltrials.gov; Unique identifier: NCT03466333.
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Affiliation(s)
- Laura Ormesher
- From the Maternal and Fetal Health Research Centre, Division of Developmental Biology and Medicine (L.O., E.C., E.D.J., J.E.M.), University of Manchester, United Kingdom
- St Mary's Hospital (L.O., H.G., E.D.J., J.E.M.), Manchester University NHS Foundation Trust, United Kingdom
| | - Suzanne Higson
- Manchester Heart Centre (S.H., M.L.), Manchester University NHS Foundation Trust, United Kingdom
| | - Matthew Luckie
- Manchester Heart Centre (S.H., M.L.), Manchester University NHS Foundation Trust, United Kingdom
| | - Stephen A Roberts
- Centre for Biostatistics (S.A.R.), University of Manchester, United Kingdom
| | - Heather Glossop
- St Mary's Hospital (L.O., H.G., E.D.J., J.E.M.), Manchester University NHS Foundation Trust, United Kingdom
| | - Andrew Trafford
- Division of Cardiovascular Sciences (A.T.), University of Manchester, United Kingdom
| | - Elizabeth Cottrell
- From the Maternal and Fetal Health Research Centre, Division of Developmental Biology and Medicine (L.O., E.C., E.D.J., J.E.M.), University of Manchester, United Kingdom
| | - Edward D Johnstone
- From the Maternal and Fetal Health Research Centre, Division of Developmental Biology and Medicine (L.O., E.C., E.D.J., J.E.M.), University of Manchester, United Kingdom
- St Mary's Hospital (L.O., H.G., E.D.J., J.E.M.), Manchester University NHS Foundation Trust, United Kingdom
| | - Jenny E Myers
- From the Maternal and Fetal Health Research Centre, Division of Developmental Biology and Medicine (L.O., E.C., E.D.J., J.E.M.), University of Manchester, United Kingdom
- St Mary's Hospital (L.O., H.G., E.D.J., J.E.M.), Manchester University NHS Foundation Trust, United Kingdom
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Herrera CL, Schell RC, McIntire DD, Cunningham FG. Pulmonary hypertension complicating pregnancy: cardiac remodeling and residual concerns. J Matern Fetal Neonatal Med 2020; 35:4104-4109. [PMID: 33228418 DOI: 10.1080/14767058.2020.1847070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To assess pulmonary artery pressure and cardiac remodeling in pregnancy in women with pulmonary hypertension and compare these findings with studies done beyond three months postpartum. STUDY DESIGN Pregnant women with pulmonary hypertension from 2006 to 2017 were studied. Pulmonary hypertension was diagnosed when the pulmonary artery pressure exceeded 30 mmHg as estimated by right ventricular systolic pressure (RVSP) on echocardiography or 20 mmHg measured directly by mean pulmonary artery pressure (PAPm) with right-heart catheterization (RHC). Disease severity was assigned using threshold cutoffs. Indices of cardiac remodeling were compared during pregnancy after 20 weeks' gestation and again beyond three months postpartum when available. Pulmonary artery pressures obtained by echocardiography versus right-heart catheterization were also compared. RESULTS Forty-six pregnancies complicated by pulmonary hypertension in 41 women were identified. The study included 43 pregnancies that resulted in a livebirth. There were 20 women in whom studies were performed after 20 weeks' gestation and again at least 3 months postpartum or later. Pulmonary artery pressures determined during pregnancy versus beyond three months postpartum were not significantly different when measured by echocardiography (RVSP 53.5 ± 20.5 mmHg and 46.7 ± 20.4 mmHg, p = .26) in this limited cohort. In the 10 women in whom pulmonary artery pressures were measured with both echocardiography and right-heart catheterization, the former was found to significantly overestimate directly measured pulmonary artery pressure (63.3 ± 20.7 versus 37.7 ± 12.3 mmHg, p < .001). CONCLUSION Pulmonary artery pressures did not appreciably change during pregnancy after 20 weeks' gestation compared with pressures measured again beyond three months postpartum. Women with pulmonary hypertension did not show evidence of remodeling of left ventricular mass or relative wall thickness when measured in pregnancy after 20 weeks' gestation compared with beyond three months postpartum in this limited cohort. These findings suggest that cardiac remodeling in women with pulmonary hypertension is different from that of normally pregnant women and confirms the need for careful long-term follow-up.
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Affiliation(s)
- Christina L Herrera
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Rachel C Schell
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Donald D McIntire
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - F Gary Cunningham
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Spiral artery blood flow during pregnancy: a systematic review and meta-analysis. BMC Pregnancy Childbirth 2020; 20:680. [PMID: 33176723 PMCID: PMC7656690 DOI: 10.1186/s12884-020-03150-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 07/31/2020] [Indexed: 11/10/2022] Open
Abstract
Background Downstream remodeling of the spiral arteries (SpA) decreases utero-placental resistance drastically, allowing sustained and increased blood flow to the placenta under all circumstances. We systematically evaluated available reports to visualize adaptation of spiral arteries throughout pregnancy by ultra-sonographic measurements and evaluated when this process is completed. Methods A systematic review and meta-analysis of spiral artery flow (pulsatility index (PI), resistance index (RI) and peak systolic velocity (PSV)) was performed. English written articles were obtained from Pubmed, EMBASE and Cochrane Library and included articles were assessed on quality and risk of bias. Weighted means of Doppler indices were calculated using a random-effects model. Results In healthy pregnancies, PI and RI decreased from 0.80 (95% CI: 0.70–0.89) and 0.50 (95% CI: 0.47–0.54) in the first trimester to 0.50 (95% CI: 0.45–0.55, p < 0.001) and 0.39 (95% CI: 0.37–0.42, p < 0.001) in the second trimester and to 0.49 (95% CI: 0.44–0.53, p = 0.752) and 0.36 (95% CI: 0.35–0.38, p = 0.037) in the third trimester, respectively. In parallel, PSV altered from 0.22 m/s (95% CI: 0.13–0.30 m/s) to 0.28 m/s (95% CI: 0.17–0.40 m/s, p = 0.377) and to 0.25 m/s (95% CI: 0.20–0.30 m/s, p = 0.560) in the three trimesters. In absence of second and third trimester Doppler data in complicated gestation, only a difference in PI was observed between complicated and healthy pregnancies during the first trimester (1.49 vs 0.80, p < 0.001). Although individual studies have identified differences in PI between SpA located in the central part of the placental bed versus those located at its periphery, this meta-analysis could not confirm this (p = 0.349). Conclusions This review and meta-analysis concludes that an observed decrease of SpA PI and RI from the first towards the second trimester parallels the physiological trophoblast invasion converting SpA during early gestation, a process completed in the midst of the second trimester. Higher PI was found in SpA of complicated pregnancies compared to healthy pregnancies, possibly reflecting suboptimal utero-placental circulation. Longitudinal studies examining comprehensively the predictive value of spiral artery Doppler for complicated pregnancies are yet to be carried out.
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Breetveld NM, Alers R, Geerts L, van Kuijk SMJ, van Dijk AP, van der Vlugt MJ, Heidema WM, van Neer J, van Empel VPM, Brunner‐La Rocca H, Scholten RR, Ghossein‐Doha C, Spaanderman MEA. Low Plasma Volume and Increased Pressure Load Relate to Concentric Left Ventricular Remodeling After Preeclampsia: A Longitudinal Study. J Am Heart Assoc 2020; 9:e015043. [PMID: 32924785 PMCID: PMC7792392 DOI: 10.1161/jaha.119.015043] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 06/18/2020] [Indexed: 12/31/2022]
Abstract
Background During uncomplicated pregnancy, left ventricular remodeling occurs in an eccentric way. In contrast, during preeclamptic gestation, the left ventricle hypertrophies concentrically, concurrent with loss in circulatory volume and increased blood pressure. Concentric cardiac structure persists in a substantial proportion of women and may be associated with pressure and volume load after preeclampsia. We hypothesize that low volume load, as indicated by plasma volume (PV) after preeclampsia and increased pressure load, is associated with remote concentric remodeling. Methods and Results In this longitudinal cohort study, we included 100 formerly preeclamptic women. Two visits were performed: at 0.8 years postpartum and at 4.8 years postpartum. During visit 1, we measured blood pressure and PV (I125 dilution technique, low PV ≤48 mL/kg lean body mass). During the second visit, we assessed cardiac geometry by cardiac ultrasound. Concentric remodeling was defined as relative wall thickness >0.42 and left ventricular mass index ≤95 g/m2. We adjusted multivariable analysis for primiparity, systolic blood pressure, PV mL/kg lean body mass, and antihypertensive medication at visit 1. Low PV is associated with remote concentric remodeling (odds ratio [OR], 4.37; 95% CI, 1.06-17.40; and adjusted OR, 4.67; 95% CI, 1.02-21.42). Arterial pressure load (systolic, diastolic, and mean arterial pressure) is also associated with development of concentric remodeling (OR, 1.15 [95% CI, 0.99-1.35]; OR, 1.24 [95% CI, 0.98-1.58]; and OR, 1.20 [95% CI, 0.98-1.47], respectively). Conclusions In former preeclamptic women, development toward left ventricular concentric remodeling is associated with low volume load and increased pressure load.
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Affiliation(s)
- Nicolette M. Breetveld
- Department of Obstetrics and GynecologyResearch School GROWMaastricht University Medical CenterMaastrichtthe Netherlands
| | - Robert‐Jan Alers
- Department of Obstetrics and GynecologyResearch School GROWMaastricht University Medical CenterMaastrichtthe Netherlands
| | - Lauren Geerts
- Department of Obstetrics and GynecologyResearch School GROWMaastricht University Medical CenterMaastrichtthe Netherlands
| | - Sander M. J. van Kuijk
- Department of Clinical Epidemiology and Medical Technology AssessmentMaastricht University Medical CenterMaastrichtthe Netherlands
| | - Arie P. van Dijk
- Department of CardiologyRadboud University Medical CenterNijmegenthe Netherlands
| | | | - Wieteke M. Heidema
- Department of Obstetrics and GynecologyRadboud University Medical CenterNijmegenthe Netherlands
| | - Jolijn van Neer
- Department of Obstetrics and GynecologyResearch School GROWMaastricht University Medical CenterMaastrichtthe Netherlands
| | | | | | - Ralph R. Scholten
- Department of Obstetrics and GynecologyRadboud University Medical CenterNijmegenthe Netherlands
| | - Chahinda Ghossein‐Doha
- Department of Obstetrics and GynecologyResearch School GROWMaastricht University Medical CenterMaastrichtthe Netherlands
| | - Marc E. A. Spaanderman
- Department of Obstetrics and GynecologyResearch School GROWMaastricht University Medical CenterMaastrichtthe Netherlands
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Mulder EG, Ghossein-Doha C, Crutsen J, Van Kuijk S, Thilaganathan B, Spaanderman M. Effect of pregnancy prolongation in early-onset pre-eclampsia on postpartum maternal cardiovascular, renal and metabolic function in primiparous women: an observational study. BJOG 2020; 128:121-129. [PMID: 32725713 PMCID: PMC7754285 DOI: 10.1111/1471-0528.16435] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2020] [Indexed: 12/12/2022]
Abstract
Objective To evaluate the association between deferred delivery in early‐onset pre‐eclampsia and offspring outcome and maternal cardiovascular, renal and metabolic function in the postpartum period. Design Observational study. Setting Tertiary referral hospital. Population Nulliparous women diagnosed with pre‐eclampsia before 34 weeks’ gestation who participated in a routine postpartum cardiovascular risk assessment programme. Women with hypertension, diabetes mellitus or renal disease prior to pregnancy were excluded. Methods Regression analyses were performed to assess the association between pregnancy prolongation and outcome measures. Main outcome measures Offspring outcome and prevalence of deviant maternal cardiovascular, renal and metabolic function. Results The study population included 564 women with a median pregnancy prolongation of 10 days (interquartile range [IQR] 4–18) who were assessed at on average 8 months (IQR 6–12) postpartum. Pregnancy prolongation after diagnosis resulted in a decrease in infant mortality (adjusted odd ratio [aOR] 0.907, 95% CI 0.852–0.965 per day prolongation). This improvement in offspring outcome was associated with an elevated risk of moderately increased albuminuria (aOR 1.025, 95% CI 1.006–1.045 per day prolongation), but not with aberrant cardiac geometry, cardiac systolic or diastolic dysfunction, persistent hypertension or metabolic syndrome. Conclusion Pregnancy prolongation in early‐onset pre‐eclampsia is associated with improved offspring outcome and survival. These effects do not appear to be deleterious to short‐term maternal cardiovascular and metabolic function but are associated with a modest increase in risk of residual albuminuria. Tweetable abstract Pregnancy prolongation in pre‐eclampsia has only a limited effect on postpartum maternal cardiovascular function. Pregnancy prolongation in pre‐eclampsia has only a limited effect on postpartum maternal cardiovascular function.
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Affiliation(s)
- E G Mulder
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - C Ghossein-Doha
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Jrw Crutsen
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Smj Van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - B Thilaganathan
- St George's University of London, Molecular and Clinical Sciences Research Institute, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Mea Spaanderman
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, Maastricht, the Netherlands
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Incremental prognostic value of global left atrial peak strain in women with new-onset gestational hypertension. J Hypertens 2020; 37:1668-1675. [PMID: 30950977 DOI: 10.1097/hjh.0000000000002086] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Left atrial strain and strain rate parameters, measured by bidimensional-speckle tracking echocardiography, have been proposed as predictors of atrial fibrillation, stroke, congestive heart failure and cardiovascular death. However, they have not yet been tested in hypertensive disorders of pregnancy. The aim of this study was to assess the prognostic role of global left atrial peak strain (GLAPS) in a population of pregnant women with new-onset hypertension in a medium-term follow-up. METHODS Twenty-seven consecutive women with new-onset hypertension after 20 weeks pregnancy and 23 age-matched, race-matched and gestational week-matched consecutive normotensive pregnant women were enrolled in this prospective study. All participants underwent a complete echocardiographic study with bidimensional-speckle tracking echocardiography and carotid examination. At 1-year follow-up, we evaluated the occurrence of persistent hypertension. RESULTS In comparison with normotensive women, those hypertensive had a higher burden of cardiovascular risk factors, similar left atrial volume indexed (P = 0.14), but severely impaired left atrial strain (P < 0.0001) and strain rate values (P < 0.0001). At 1-year follow-up, persistent hypertension was documented in 59.3% of patients. At the univariate Cox analysis, the variables associated with the occurrence of the investigated outcome in all hypertensive pregnancies were SBP (hazard ratio 1.04, P = 0.04), DBP (hazard ratio 1.11, P = 0.01), mean arterial pressure (hazard ratio 1.09, P = 0.01) values and the GLAPS value (hazard ratio 0.85, P = 0.0019). The latter was significantly associated with the investigated outcome both in preeclamptic (hazard ratio 0.84, P = 0.02) and nonpreeclamptic pregnant women (hazard ratio 0.83, P = 0.04). The receiver operating characteristics curve analysis highlighted that a GLAPS value of 23.5% or less predicted persistent hypertension with sensitivity of 100% and specificity of 90.90%. CONCLUSION In hypertensive pregnant women a GLAPS value of 23.5% or less reveals a greater severity of atrial cardiomyopathy and might predict postpregnancy persistent hypertension.
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Ramlakhan KP, Johnson MR, Roos-Hesselink JW. Pregnancy and cardiovascular disease. Nat Rev Cardiol 2020; 17:718-731. [PMID: 32518358 DOI: 10.1038/s41569-020-0390-z] [Citation(s) in RCA: 126] [Impact Index Per Article: 25.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/30/2020] [Indexed: 12/13/2022]
Abstract
Cardiovascular disease complicates 1-4% of pregnancies - with a higher prevalence when including hypertensive disorders - and is the leading cause of maternal death. In women with known cardiovascular pathology, such as congenital heart disease, timely counselling is possible and the outcome is fairly good. By contrast, maternal mortality is high in women with acquired heart disease that presents during pregnancy (such as acute coronary syndrome or aortic dissection). Worryingly, the prevalence of acquired cardiovascular disease during pregnancy is rising as older maternal age, obesity, diabetes mellitus and hypertension become more common in the pregnant population. Management of cardiovascular disease in pregnancy is challenging owing to the unique maternal physiology, characterized by profound changes to multiple organ systems. The presence of the fetus compounds the situation because both the cardiometabolic disease and its management might adversely affect the fetus. Equally, avoiding essential treatment because of potential fetal harm risks a poor outcome for both mother and child. In this Review, we examine how the physiological adaptations during pregnancy can provoke cardiometabolic complications or exacerbate existing cardiometabolic disease and, conversely, how cardiometabolic disease can compromise the adaptations to pregnancy and their intended purpose: the development and growth of the fetus.
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Affiliation(s)
- Karishma P Ramlakhan
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Mark R Johnson
- Academic Department of Obstetrics and Gynaecology, Imperial College London, Chelsea and Westminster Hospital, London, UK
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Lekva T, Sugulle M, Moe K, Redman C, Dechend R, Staff AC. Multiplex Analysis of Circulating Maternal Cardiovascular Biomarkers Comparing Preeclampsia Subtypes. Hypertension 2020; 75:1513-1522. [PMID: 32336238 DOI: 10.1161/hypertensionaha.119.14580] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Preeclampsia, a hypertensive pregnancy disorder, links to increased long-term maternal cardiovascular disease (CVD). The risk is further increased with early-onset preeclampsia (EPE) and delivery of a growth-restricted child. We hypothesized that circulating biomarkers associated with CVD risk differed between preeclampsia subtypes and controls. We compared EPE; n=37, delivery <week 34, late-onset preeclampsia (LPE); n=29, delivery ≥week 34, and normotensive controls (n=49) using Olink Proseek multiplex CVD I assay (targeting 92 biomarkers). We stratified analysis to uteroplacental spiral artery acute atherosis presence in preeclampsia patients, sharing morphological similarities with atherosclerosis. We found 47 CVD-related biomarkers differing between the groups, 42 markers between normotensive controls and EPE, 28 markers between normotensive controls and LPE, and 9 markers between EPE and LPE. Among these 9 markers, ST2 (ST2 protein), MMP (matrix metalloproteinase) 1, MMP3, and fractalkine (CX3CL1) were uniquely dysregulated in EPE. Principal component (PC) analysis of the differing markers identified 4 clusters (named PC1-PC4) that largely separated the preeclampsia and control groups as well as pregnancies with low and high circulating PlGF (placental growth factor). The combination of the single markers PlGF, ST2, MMP1, MMP3, and CX3CL1 had a high discriminatory property to differentiate between EPE and LPE. Preeclampsia with acute atherosis or with fetal growth restriction could be differentiated by Olink biomarkers as compared with preeclampsia without these features. We identified specific CVD-related biomarkers in pregnancy depending on preeclampsia subtypes and uteroplacental acute atherosis. Assessment of these pregnancy measured biomarkers' relation to long-term cardiovascular dysfunction and hard end points is warranted.
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Affiliation(s)
- Tove Lekva
- From the Department of Obstetrics and Gynecology, Oslo University Hospital, Ullevål, Norway (T.L., M.S., K.M., A.C.S.).,Research Institute of Internal Medicine, Oslo University Hospital, Rikshospitalet, Norway (T.L.)
| | - Meryam Sugulle
- From the Department of Obstetrics and Gynecology, Oslo University Hospital, Ullevål, Norway (T.L., M.S., K.M., A.C.S.).,Faculty of Medicine, University of Oslo, Norway (M.S., K.M., A.C.S.)
| | - Kjartan Moe
- From the Department of Obstetrics and Gynecology, Oslo University Hospital, Ullevål, Norway (T.L., M.S., K.M., A.C.S.).,Faculty of Medicine, University of Oslo, Norway (M.S., K.M., A.C.S.).,Department of Gynecology and Obstetrics, Bærum Hospital, Vestre Viken HF, Norway (K.M.)
| | | | - Ralf Dechend
- Experimental and Clinical Research Center, a cooperation of Charité-Universitätsmedizin Berlin and Max-Delbruck Center for Molecular Medicine, Germany (R.D.).,Department of Cardiology and Nephrology, HELIOS-Klinikum, Berlin, Germany (R.D.)
| | - Anne Cathrine Staff
- From the Department of Obstetrics and Gynecology, Oslo University Hospital, Ullevål, Norway (T.L., M.S., K.M., A.C.S.).,Faculty of Medicine, University of Oslo, Norway (M.S., K.M., A.C.S.)
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Sutton EF, Gemmel M, Powers RW. Nitric oxide signaling in pregnancy and preeclampsia. Nitric Oxide 2020; 95:55-62. [DOI: 10.1016/j.niox.2019.11.006] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 10/10/2019] [Accepted: 11/22/2019] [Indexed: 01/08/2023]
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Reddy M, Wright L, Rolnik DL, Li W, Mol BW, La Gerche A, da SilvaCosta F, Wallace EM, Palmer K. Evaluation of Cardiac Function in Women With a History of Preeclampsia: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2019; 8:e013545. [PMID: 31698969 PMCID: PMC6915290 DOI: 10.1161/jaha.119.013545] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background Women with a history of preeclampsia are at increased risk of cardiovascular morbidity and mortality. However, the underlying mechanisms of disease association, and the ideal method of monitoring this high‐risk group, remains unclear. This review aims to determine whether women with a history of preeclampsia show clinical or subclinical cardiac changes when evaluated with an echocardiogram. Methods and Results A systematic search of MEDLINE, EMBASE, and CINAHL databases was performed to identify studies that examined cardiac function in women with a history of preeclampsia, in comparison with those with normotensive pregnancies. In the 27 included studies, we found no significant differences between preeclampsia and nonpreeclampsia women with regard to left ventricular ejection fraction, isovolumetric relaxation time, or deceleration time. Women with a history of preeclampsia demonstrated a higher left ventricular mass index and relative wall thickness with a mean difference of 4.25 g/m2 (95% CI, 2.08, 6.42) and 0.03 (95% CI, 0.01, 0.05), respectively. In comparison with the nonpreeclampsia population, they also demonstrated a lower E/A and a higher E/e′ ratio with a mean difference of −0.08 (95% CI, −0.15, −0.01) and 0.84 (95% CI, 0.41, 1.27), respectively. Conclusions In comparison with women who had a normotensive pregnancy, women with a history of preeclampsia demonstrated a trend toward altered cardiac structure and function. Further studies with larger sample sizes and consistent echocardiogram reporting with the use of sensitive preclinical markers are required to assess the role of echocardiography in monitoring this high‐risk population group.
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Affiliation(s)
- Maya Reddy
- Department of Obstetrics and Gynaecology Monash University Melbourne Victoria Australia.,Monash Women's Monash Health Melbourne Victoria Australia
| | - Leah Wright
- Baker Heart and Diabetes Institute Melbourne Victoria Australia
| | - Daniel Lorber Rolnik
- Department of Obstetrics and Gynaecology Monash University Melbourne Victoria Australia.,Monash Women's Monash Health Melbourne Victoria Australia
| | - Wentao Li
- Department of Obstetrics and Gynaecology Monash University Melbourne Victoria Australia
| | - Ben Willem Mol
- Department of Obstetrics and Gynaecology Monash University Melbourne Victoria Australia
| | - Andre La Gerche
- Baker Heart and Diabetes Institute Melbourne Victoria Australia.,Department of Cardiology St Vincent's Hospital Melbourne Victoria Australia
| | - Fabricio da SilvaCosta
- Department of Obstetrics and Gynaecology Monash University Melbourne Victoria Australia.,Department of Gynecology and Obstetrics Ribeirão Preto Medical School University of São Paulo Ribeirão Preto Brazil
| | - Euan M Wallace
- Department of Obstetrics and Gynaecology Monash University Melbourne Victoria Australia
| | - Kirsten Palmer
- Department of Obstetrics and Gynaecology Monash University Melbourne Victoria Australia.,Monash Women's Monash Health Melbourne Victoria Australia
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Kawamatsu N, Ishizu T, Kawakami Y. What We Know and What We Don't Know About the Adaptation to Pregnancy and Left Ventricular Diastolic Dysfunction. Circ J 2019; 83:2205-2207. [PMID: 31611538 DOI: 10.1253/circj.cj-19-0827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Naoto Kawamatsu
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | - Tomoko Ishizu
- Department of Clinical Laboratory Medicine, Faculty of Medicine, University of Tsukuba
| | - Yasushi Kawakami
- Department of Clinical Laboratory Medicine, Faculty of Medicine, University of Tsukuba
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Preeclampsia: The Relationship between Uterine Artery Blood Flow and Trophoblast Function. Int J Mol Sci 2019; 20:ijms20133263. [PMID: 31269775 PMCID: PMC6651116 DOI: 10.3390/ijms20133263] [Citation(s) in RCA: 122] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 06/27/2019] [Accepted: 06/28/2019] [Indexed: 12/29/2022] Open
Abstract
Maternal uterine artery blood flow is critical to maintaining the intrauterine environment, permitting normal placental function, and supporting fetal growth. It has long been believed that inadequate transformation of the maternal uterine vasculature is a consequence of primary defective trophoblast invasion and leads to the development of preeclampsia. That early pregnancy maternal uterine artery perfusion is strongly associated with placental cellular function and behaviour has always been interpreted in this context. Consistently observed changes in pre-conceptual maternal and uterine artery blood flow, abdominal pregnancy implantation, and late pregnancy have been challenging this concept, and suggest that abnormal placental perfusion may result in trophoblast impairment, rather than the other way round. This review focuses on evidence that maternal cardiovascular function plays a significant role in the pathophysiology of preeclampsia.
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Cardiac remodeling in morbidly obese women and its association with adverse perinatal outcomes. Pregnancy Hypertens 2019; 17:104-108. [PMID: 31487624 DOI: 10.1016/j.preghy.2019.05.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 05/05/2019] [Accepted: 05/23/2019] [Indexed: 01/02/2023]
Abstract
OBJECTIVES To determine the association of cardiac remodeling in early pregnancy and adverse perinatal outcomes among women with BMI ≥ 40 kg/m2. STUDY DESIGN We performed a retrospective cohort study including women with BMI ≥ 40 kg/m2 without known cardiac disease. Women who underwent screening transthoracic echocardiography prior to gestational age 24 weeks were included. Women were analyzed by group with normal or abnormal geometry, including concentric remodeling, eccentric hypertrophy, and concentric hypertrophy. Multivariable logistic regression was used to assess the association of abnormal geometry with perinatal outcomes. We had 80% power with alpha 0.05 to detect a 3.0-fold increase in the primary outcome among women with abnormal geometry. MAIN OUTCOME MEASURES Our primary outcome was a composite of adverse perinatal outcomes including any 1 of the following: preterm birth (<37 weeks), low birth weight (<2500 g), or hypertensive disorders of pregnancy, including gestational hypertension, preeclampsia, and chronic hypertension with superimposed preeclampsia. RESULTS Of 140 women, 53 (37.9%) had abnormal geometry. The average BMI was similar between those with normal and abnormal geometry (44.7 vs. 44.2 kg/m2, p = 0.53). The primary outcome occurred in 20.7% with normal geometry and 30.2% with abnormal geometry (p = 0.20). After adjustment for parity, chronic hypertension, and tobacco use, abnormal cardiac geometry was not associated with the composite primary outcome (adjusted OR 2.01 [95% CI 0.84-4.78]) but was associated with hypertensive disorders of pregnancy (adjusted OR 2.82 [95% CI 1.03-7.78]). CONCLUSIONS Cardiac remodeling early in pregnancy is associated with hypertensive disorders of pregnancy.
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