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Validation of Risk Scoring Systems in Predicting Adverse Cardiac Outcomes in Pregnant Women With Valvular Heart
Malini Sukayogula1, Tarakeswari Surapaneni1, Anish Keepanasseril2
1Department of Obstetrics and Gynecology, and Obstetric Medicine, Fernandez Hospital, Hyderabad, Telangana 500029, India.
Insights
The DEVI score best predicts adverse cardiac events in pregnant women with valvular heart disease (VHD). This tool is recommended for risk stratification, especially in resource-limited settings.
Area of Science:
- Cardiology
- Maternal-Fetal Medicine
- Public Health
Background:
- Valvular heart disease (VHD) poses significant risks during pregnancy.
- Accurate risk stratification is crucial for managing pregnant women with VHD.
- Existing tools require validation in diverse populations.
Purpose of the Study:
- To compare the performance of four risk stratification tools: DEVI score, ZAHARA score, CARPREG II, and modified WHO (mWHO) classification.
- To assess their ability to predict adverse cardiac events in pregnant women with VHD.
- To evaluate their clinical utility, particularly in resource-limited settings.
Main Methods:
- Retrospective cohort study at a tertiary care center in India (2011-2023).
- Inclusion of 176 women and 205 pregnancies.
- Assessment of discriminative ability using AUC, calibration via plots, and clinical utility via DCA.
Main Results:
- The DEVI score showed the highest discrimination (AUC=0.846), followed by mWHO (AUC=0.826), CARPREG II (AUC=0.762), and ZAHARA (AUC=0.716).
- Calibration plots indicated risk overestimation for DEVI and CARPREG II at higher probabilities.
- Decision curve analysis demonstrated net clinical benefit for DEVI and CARPREG II.
Conclusions:
- The DEVI score exhibits superior discriminative performance for adverse cardiac events in pregnant women with VHD.
- Its performance is comparable to CARPREG II in terms of calibration and clinical utility.
- The DEVI score is a valuable tool for risk stratification, especially in settings with a high prevalence of rheumatic VHD.
Objective:
To validate and compare the performance of four risk stratification tools-the DEVI (Adverse Cardiac Events in Valvular Rheumatic Heart Disease in Pregnancy) score, Zwangerschap bij Aangeboren Hartafwijking (ZAHARA) score, Cardiac Disease in Pregnancy II (CARPREG II), and modified WHO (mWHO) classification-in predicting adverse cardiac events during pregnancy in women with valvular heart disease (VHD).
Methods:
This retrospective cohort study was conducted at Fernandez Hospital, a tertiary care referral center in Hyderabad, India, utilizing clinical data from pregnancies managed between January 2011 and December 2023. The primary outcome was the development of composite adverse cardiac events. Discriminative ability was assessed using the area under the receiver operating characteristic curve (AUC), calibration was evaluated via calibration plots, and clinical utility was determined by decision curve analysis (DCA). Categorical variables were reported as frequencies and percentages and continuous variables were presented as means with standard deviations or medians with interquartile ranges. Individual risk assessment was conducted using both the CARPREG II and DEVI risk stratification models, while the ZAHARA score was calculated by aggregating weighted parameters according to established scoring criteria.
Results:
The study enrolled 176 women and analyzed 205 pregnancies with adverse cardiac events in 19 pregnancies (9.3%). The DEVI score demonstrated superior discrimination (AUC = 0.846, 95% CI: 0.765-0.927, P < 0.001), followed by mWHO (AUC = 0.826, 95% CI: 0.736-0.917, P < 0.001), CARPREG II (AUC = 0.762, 95% CI: 0.652-0.872, P < 0.001), and ZAHARA (AUC = 0.716, 95% CI: 0.628-0.803, P < 0.001). Calibration plots revealed an overestimation of risk at higher probabilities for DEVI and CARPREG II. DCA indicated net clinical benefit for both tools at 10-30% threshold probabilities.
Conclusion:
The DEVI score showed the highest discriminative performance, though its calibration and clinical utility were comparable to CARPREG II. These findings support its use for risk stratification in pregnant women with VHD, particularly in resource-limited settings where rheumatic VHD predominates.
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