Pregnancy & cardiovascular disease: the PREG-CVD-HH registry

Cardiovascular disease (CVD) remains the leading cause of death in pregnant and peripartal women in western countries. Physiological changes during pregnancy can lead to cardiovascular complications in the mother; women with pre-existing heart disease may not tolerate these changes well, increasing their susceptibility to adverse cardiovascular outcomes during pregnancy. The aim of this study is to characterize pregnancy-induced changes in cardiac function, biomarker concentrations and cardiovascular outcomes in women with CVD during pregnancy at a tertiary care hospital in Germany.

The PREG-CVD-HH study is a prospective single-center observational study of pregnant women with prevalent CVD treated at the University Medical Center Hamburg, Germany and currently includes 63 women with congenital or acquired heart disease and ten women from the general population included as controls. Participants underwent baseline assessment and dedicated comprehensive echocardiography. Biomarkers N-terminal pro B-type natriuretic peptide (NT-proBNP), MR-proadrenomedullin (MRproADM) and high-sensitivity cardiac troponin I (hs-cTnI) were measured serially throughout pregnancy and until 6 and 12 months postpartum. A maternal cardiac event was defined as death due to cardiovascular cause, arrhythmia, heart failure or hospitalization for other cardiac intervention.

Mean maternal age was 34 years. A majority had a congenital heart disease (N=41), 10 patients developed pregnancy-associated CVD (e.g., preeclampsia, peripartum cardiomyopathy) and 12 women had known acquired heart disease (e.g., valvular disease, arrhythmia, cardiomyopathy). New-onset heart failure was observed in 14.1% of patients (N=9). Five patients developed arrhythmia and three patients developed preeclampsia. About 21.2% of patients were hospitalized due to cardiovascular events. Death from any or cardiovascular cause did not occur over the study period. Left and right ventricular global longitudinal strain (LV GLS, RV GLS) showed a transient worsening in the third trimester and peripartum period. NT-proBNP ranges broadened during the pregnancy and tended to progressively decrease postpartum in women with CVD. Hs-cTnI levels tended to trend upwards during pregnancy in patients with CVD, however, the hs-cTnI levels remained consistently low throughout pregnancy.

In our cohort, pregnancy was associated with a transient increase in cardiac biomarkers and worsening of cardiac function during the third trimester and peripartum. These temporal changes reversed at 6-12 months postpartum, potentially due to decreased cardiac load, fluid shifts and hormonal changes. Overall, data on reference ranges in echocardiographic and biomarker measurements in the pregnant cardiac population are limited and require further investigation. Albeit one third of our cohort was deemed at high and highest maternal risk during pregnancy, there was no maternal death. We recommend that women with CVD receive preconceptional counselling and ongoing management by a specialized "Pregnancy Heart Team" to optimize care and, potentially, maternal outcomes.