Burden of left ventricular systolic dysfunction and response to treatment in pregnancy: insights from the prospective Pakistan registry of echocardiographic screening in asymptomatic pregnant women
S Bhatti, S Gurmani, H Yasmin, S Ahmad, S Naz, U Atif, M KarimAbstract
Background
Cardiovascular diseases (CVD) are the primary cause of non-obstetric morbidity and mortality in pregnant women worldwide. Pakistan's high maternal and neonatal mortality rates underscore the need for effective screening protocols to detect CVD during pregnancy. Asymptomatic and undiagnosed left ventricular systolic dysfunction (LVSD) may lead to adverse maternal and fetal outcomes. Response to treatment of asymptomatic LVSD has not been studied in this population.
Purpose
Implementing cardiac screening during obstetric appointments provides an opportunity for early diagnosis, treatment, and follow-up, potentially improving outcomes. PRESAP registry, a prospective study of echocardiographic screening in consecutive asymptomatic pregnant women represents various regions across Pakistan. This is a sub study evaluating the burden of LVSD by TTE and the response to medical therapy.
Methods
Consecutive obstetric patients attending routine antenatal visits were enrolled in this ongoing registry during a 2 year period. A standardized limited 2D transthoracic echocardiogram (TTE) protocol was employed. Ejection fraction (EF) was quantified using biplane Simpson's method. Patients who were available for follow up and underwent a follow up echo were included in this sub analysis from PRESAP.
Results
We enrolled 28,298 consecutive pregnant women of which 778(2.8%) had LVSD. 6 month Follow up was available for 183 of these patients. Mean age was 26.2 ± 5.1 years, with 77% being multigravidas. Screening occurred in the second trimester for 21.3% of patients and in the third trimester for 73.2%. Among the patients with LVSD, 29% had severely reduced function (Ef <30%) and 35% had moderately reduced function (31-40%). All patients with abnormal findings on TTE were referred to CardioOb clinic for treatment and further management. Patients were started on medical therapy for LVSD as indicated and uptitrated as tolerated. At 6 month follow up on repeat TTE, 41.3% showed improved function whereas 11% showed worsened function. The remainder had no change on TTE.
Conclusion
Asymptomatic pregnant women undergoing routine antenatal visits showed a considerable prevalence of LVSD. Notably, 2.8% of screened women had asymptomatic LVSD. The etiologies of the LVSD in earlier trimesters were likely residual peripartum cardiomyopathy from prior pregnancies, genetic, and hypertensive cardiomyopathies. All patients were referred to CardioOb clinic however only a small proportion returned for clinical follow up and TTE. At 6 month followup 41.3% showed improved function. This study highlights the importance of early diagnosis and treatment of LVSD in pregnancy in high prevalence areas. Larger studies are needed.