An analysis of the impact of adverse pregnancy outcomes on downstream prevalence of heart strain - an interim report from the Her-Heartbeat Project
J Lahkar, S Oneill, Z Zahid, D Twomey, A O' Higgins, B Dalton, M Ryder, M Ledwidge, J Gallagher, F Perez-Rastelli, J Maher, K Mc DonaldAbstract
Introduction
Adverse Pregnancy Outcomes (APO) characterised by a group of diseases including gestational hypertension (GHT), gestational diabetes mellitus (GDM), preeclampsia, intrauterine growth restriction (IUGR), placental abruption (PA) and pre-term birth, have a high prevalence and manifest in 10 to 20% of all pregnancies (1). APOs are associated with an increased risk in developing future cardiovascular disease (CVD), including heart failure (HF)(2). The established links between APOs and CVD highlights the importance of increased preventative measures (2). However, the correlation of APOs and the preclinical at-risk phase of HF are not well established. The "Her Heartbeat Project" screens women with known APOs for preclinical HF using natriuretic peptide (NP). This is a preliminary report of our ongoing project to determine the prevalence of abnormal BNP and signs of heart strain in this patient group
Methods
We asked general practitioners in our established research network to screen women with known APOs for HF with NP. APOs are defined as GHT, GDM, preeclampsia, IUGR, PA and early (born before the 34th week of pregnancy) and late (born between the 34thand 36th week of pregnancy) pre-term birth. Women with a NTproBNP of > 125 pg/ml or a BNP of > 50 pg/ml are referred for Doppler-echocardiographic study to assess for signs of preclinical heart strain, defined by ≥ 1 of the following features: Mean E/e’ > 13, left ventricular mass indexed (LVMI) to body surface area (BSA) of > 110 g/m2, at least moderate valvular disease, left atrial volume indexed (LAVI) to BSA of > 34 ml/m2 and an ejection fraction (EF) of < 50%. Additionally, patients are reviewed by a cardiologist and a clinical nurse specialist to establish the possible undiagnosed HF
Results
69 of the target 300 women have been enrolled to date. The average age was 49.1 with an average BMI of 31.4. 35% of women had hypertension, 26% dyslipidaemia and 11% diabetes. The mean NT-proBNP was 67.0 pg/ml and the mean BNP was 59 pg/ml, showing an abnormal NP in 13% of patients. The most common APO was GDM in 60%, followed by GHT in 29% and preeclampsia in 28%. 4 women had a PA and 4 children experienced IUGR . 5 children were born early and 10 late pre-term. The average number of pregnancies was 2.6. To date 56% (5 patients) show features of heart strain. 33% had a LAVI > 34ml/m2, 33% had at least moderate valvular disease and 22% had an E/e’ > 13 with 3 women presenting with > 1 feature. None of the assessed patients had clinical symptoms of HF
Conclusion
The early data from this ongoing study demonstrate a concerning prevalence of cardiac abnormality in a relatively young population supporting the link between APO and downstream CV risk, especially risk for HF development. Establishing preventative strategies in the early post-partum stage may have significant impact on prevention of HF and wider CV presentations. The optimal method to structure such a service requires further study