Severe pre-eclampsia exerts acute effects on the geometry and function of the heart, a new study confirms.
Notably, the study found left atrial enlargement, increased left ventricular (LV) mass, diastolic dysfunction, and reduced right ventricular (RV) strain in women with pre-eclampsia with severe features.
"I hope this study helps clinicians realize that pre-eclampsia can cause cardiac remodeling and abnormal cardiac parameters at the time of diagnosis," Arthur Jason Vaught, MD, from Johns Hopkins University School of Medicine, Baltimore, Maryland, told theheart.org | Medscape Cardiology.
Their findings are published online June 25 in the Journal of the American College of Cardiology.
The "Twilight Zone"
Pre-eclampsia complicates 2% to 8% of all pregnancies and within 15 years is associated with a two- to sevenfold increased risk for cardiovascular disease (CVD), the researchers note.
In this context, pre-eclampsia "may be viewed upon as the 'twilight zone' between health and disease," suggest the authors of an editorial published with the study.
Several prior studies have focused on the CV and clinical characteristics associated with pre-eclampsia, but few have focused on women with pre-eclampsia with severe features or have correlated echocardiographic findings with short-term CV events.
To help fill the gap, Vaught and colleagues compared cardiac function using transthoracic echocardiography in a racially diverse cohort of 63 women with severe pre-eclampsia and a control group of 36 women with normotensive pregnancies.
Severe pre-eclampsia was characterized by systolic blood pressure of 160 mm Hg or greater or a diastolic blood pressure of 110 mm Hg or greater measured on two occasions at least 4 hours apart, as well as proteinuria greater than 300 mg of protein in a 24-hour urine collection or a protein/creatinine ratio of at least 0.3 on urinalysis.
Compared with controls, women with severe pre-eclampsia had higher RV systolic pressures (RVSP) and diminished RV longitudinal systolic strain (RVLSS).
Table. Cardiac Endpoints in Pre-eclampsia vs Control Cohorts
|Endpoint||Pre-eclampsia Cohort||Control Cohort||P Value|
|RVSP (mm Hg)||31.0 ± 7.9||22.5 ± 6.1||<.001|
|RVLSS (%)||–19.6 ± 3.2||–23.8 ± 2.9||<.001|
Differences were also seen in left-sided cardiac parameters, including the following:
Mitral septal e' velocity (9.6 ± 2.4 cm/s vs 11.6 ± 1.9 cm/s);
Septal E/e' ratio (10.8 ± 2.8 vs 7.4 ± 1.6);
Left atrial size (20.1 ± 3.8 cm2 vs 17.3 ± 2.9 cm2); and
Posterior and septal wall thickness (median [interquartile range]: 1.0 cm [0.9 - 1.1 cm] vs 0.8 cm [0.7 - 0.9 cm], and 1.0 cm [0.8 - 1.2 cm] vs 0.8 cm [0.7 - 0.9 cm]).
Importantly, eight women (12.7%) with severe pre-eclampsia had grade II diastolic dysfunction and six women (9.5%) had pulmonary edema, Vaught and colleagues report.
All of the women who developed pulmonary edema had abnormally elevated septal E/e' ratios, which suggests high LV filling pressures and diastolic dysfunction, they point out.
"Our findings suggest that greater use of echocardiography in patients with severe pre-eclampsia may help identify particularly high-risk women and help improve clinical outcomes. Imaging findings could also affect fluid management strategies and antihypertensive therapies, especially in patients with elevated RVSP levels, RV abnormalities, or E/e' ratios," they write.
B-type natriuretic peptide (BNP), a marker of increased myocardial stress, was higher in women who developed pulmonary edema, although not statistically so, probably due to the study's limited power and conservative P value after application of Bonferroni correction, the investigators say.
They point out that other studies have found increased BNP and N-terminal pro-BNP levels in association with pre-eclampsia. Elevated BNP levels "may help identify women at higher risk of developing pulmonary edema, although larger cohort studies measuring BNP levels at multiple time points are needed to definitively determine the risk of developing short-term cardiovascular events," write Vaught and colleagues.
Looking at the big picture, Vaught said, "We know that the long term outcome for women with a history of pre-eclampsia is a higher risk of stroke, chronic hypertension, thromboembolism, and heart failure. However, we do not know the sub-acute and long term effects of women with the specific changes found in our manuscript."
"My inclination," said Vaught, "is that these are the women that end up having chronic cardiovascular conditions, but more research should be done in this area. If we can precisely determine which woman will have long term cardiovascular damage and illness, we can tailor clinical practice to help assure cardiovascular health."
"I hope this work further pushes other clinical scientists to study women affected by pre-eclampsia, so practitioners can better understand how to promote cardiovascular health for them in the future," Vaught told theheart.org | Medscape Cardiology.
In their editorial, Chahinda Ghossein-Doha, MD, from Maastricht University Medical Center, the Netherlands, and colleagues say this study has "highlighted again in an elegant way 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 study "supports the concept that pregnancy should be valued as a sex-specific, women-sensitive CV stress test, and the necessity to use novel methods in order to detect early stage abnormalities in the twilight zone between health and disease," they write.
"Future studies," they conclude, "should focus on the predictive value of cardiac strain abnormalities in pregnancy outcome, long-term CV outcome and the effect of different antihypertensive drug on normalizing cardiac function and with it, short- and long-term female health prognosis."
The study was funded by a Johns Hopkins University School of Medicine Synergy Award. The authors and editorial writers have disclosed no relevant financial relationships.
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Cite this: Pre-eclampsia Linked to Changes in Cardiac Geometry, Function - Medscape - Jun 29, 2018.