Results suggest that women with echocardiographic abnormalities may benefit from serial clinical and imaging follow-up
Severe pre-eclampsia can result in short-term adverse cardiovascular effects, according to results of a prospective observational comparison of echocardiographic and laboratory parameters of 99 pregnant women with or without pre-eclampsia.
Among 63 women who had pre-eclampsia with severe features (PEC), 13% had echocardiographic evidence of diastolic dysfunction, 39% had reduced right ventricular strain, and 10% developed pulmonary edema, reported Arthur Jason Vaught, MD, of Johns Hopkins University School of Medicine in Baltimore, and colleagues.
The PEC cohort had higher right ventricular (RV) systolic pressure (RVSP) (31.0 versus 22.5 mm Hg; P < 0.001) and decreased global RV longitudinal systolic strain (RVLSS) (-19.6 versus -23.8; P < 0.0001) when compared with the control cohort, researchers reported online in the Journal of the American College of Cardiology.
For left-sided cardiac parameters, there were differences (P < 0.001) in mitral septal e' velocity (9.6 versus 11.6 cm/s), septal ratio between early mitral inflow velocity, and mitral annular early diastolic velocity (E/e') (10.8 versus 7.4), left atrial (LA) area size (20.1 versus 17.3 cm2), and posterior and septal wall thickness (median 1.0 cm versus 0.8 cm, and 1.0 cm versus 0.8 cm).
"In a racially diverse cohort, women with pre-eclampsia with severe features had higher RVSP levels, diminished RVLSS, increased LA size, abnormal left ventricular (LV) cardiac relaxation, increased LV wall thickness, and increased LV filling pressures," the researchers wrote. "Another important finding is that 13% of PEC participants had grade II diastolic dysfunction. Our results provide further evidence that diastolic dysfunction and LV remodeling occur during preeclampsia."
Pre-eclampsia -- i.e., sustained blood pressure of 160 mm Hg or 110 mm Hg systolic and diastolic -- often superimposed upon chronic hypertension, complicates 2% to 8% of all pregnancies and, in case of early-onset disease, is often associated with defective placentation and serious fetal and maternal complications. Over the longer term, maternal risks for cardiovascular disease are increased two- to seven-fold within 15 years of pregnancy complicated by pre-eclampsia.
Enrollment for the study was limited to pregnant women with PEC and normotensive controls. The investigators said that the study cohort represents a unique high-risk population with a high proportion of U.S. black women -- known to have higher rates of both short- and long-term morbidity and mortality -- and women who presented with pre-eclampsia before 34 weeks gestation.
Except for a higher proportion of black women in the pre-eclampsia group, the characteristics of the two study groups were comparable, with a mean gestational age of about 32 weeks. Among the patients with PEC, 17 had pre-existing chronic hypertension, while 46 did not.
"We speculate that women diagnosed with PEC and with diastolic dysfunction, abnormal strain parameters, LV remodeling, and/or elevated RVSP are more likely to develop short-term adverse cardiovascular outcomes, such as pulmonary edema -- which was noted in 10% of women with pre-eclampsia, which is two to three times higher than rates previously reported," Vaught et al wrote.
They explained that while several factors including routine administration of magnesium sulfate can contribute to pulmonary edema, cardiac dysfunction likely played a contributing role, given that all the affected women had abnormally elevated septal E/e' ratios suggestive of high LV filling pressures and diastolic dysfunction.
"It is possible that these same abnormal echocardiographic parameters predict long-term cardiovascular events. Women with echocardiographic abnormalities may benefit from serial clinical and imaging follow-up, and aggressive postpartum surveillance and treatment of their cardiovascular risk factors."
The women who developed pulmonary edema also had higher levels of B-type natriuretic peptide (BNP), a biomarker of increased myocardial stress. Although the difference did not reach statistical significance in this small cohort, "elevated BNP levels may help identify women at higher risk of developing pulmonary edema, although [larger studies over] multiple time points are needed, the authors stated.
Asked for his perspective, James N. Martin Jr., MD, of the University of Mississippi Medical Center in Jackson, who was not involved in the study, told MedPage Today via email that the finding of 10% pulmonary edema is not surprising: "It is important that physicians control severe hypertension and avoid fluid overload, and have a low threshold for consulting cardiology for cardiac evaluation in the pregnant or recently pregnant patient with signs or symptoms of cardiac compromise."
He said that based on past observations of a higher than average risk of pulmonary edema in such patients, his center began to routinely administer furosemide immediately postpartum and for the next 4 to 5 days so that the risk of pulmonary edema could be lessened, blood pressure better controlled, and the need for antihypertensives reduced; studies of this approach are ongoing, Martin said.
Writing in an accompanying editorial titled "Pre-eclampsia: A Twilight Zone Between Health and Cardiovascular Disease?" Chahinda Ghossein-Doha, MD, of Maastricht University Medical Centre in the Netherlands, and colleagues said the study "elegantly highlights the occult aberrant cardiac adaptation during severe pre-eclampsia and shows that not only LV diastolic and systolic function may be impaired, but for the first time, also impaired RV longitudinal systolic strain. The results support the concept that pregnancy should be valued as a sex-specific, women-sensitive CV stress test, and the necessity to use novel methods [such as speckle tracking echocardiography used in this study] in order to detect early stage abnormality in the twilight zone between health and disease."
Vaught, et al noted that limitations include the study's limited power, technical challenges in obtaining accurate echocardiographic measures, possible confounding due to use of magnesium sulfate in the PEC patients but not controls, lack of assessment of preexisting and sustained cardiac dysfunction, and the fact that control and PEC patients were matched only by gestational age.
The study was funded by a Johns Hopkins University School of Medicine Synergy Award.
Vaught reported having no conflicts of interest; one co-author reported support from the Johns Hopkins Center for Child and Community Health Research-Biostatistics, Epidemiology and Data Management Core.
Ghossein-Doha and co-authors reported having no relevant disclosures.
Journal of the American College of Cardiology
Source Reference: Vaught AJ, et al "Acute Cardiac Effects of Severe Pre-Eclampsia" J Am Coll Cardiol 2018; 72: 1–11.
Journal of the American College of Cardiology
Source Reference: Ghossein-Doha C, et al "Pre-Eclampsia: A Twilight Zone Between Health and Cardiovascular Disease?" J Am Coll Cardiol 2018; 72: 12-16.
Read the original article on Medpage Today: Severe Pre-eclampsia Linked with Short-term Adverse CV Changes