Heart failure with preserved ejection fraction in women: the Dutch Queen of Hearts program

Heart failure (HF) poses a heavy burden on patients, their families and society. The syndrome of HF comes in two types: with reduced ejection fraction (HFrEF) and preserved ejection fraction (HFpEF). The latter is on the increase and predominantly present in women, especially the older ones. There is an urgent need for mortality-reducing drugs in HFpEF, a disease affecting around 5 % of those aged 65 years and over. HFpEF develops in patients with risk factors and comorbidities such as obesity, hypertension, diabetes, COPD, but also preeclampsia. These conditions are likely to drive microvascular disease with involvement of the coronary microvasculature, which may eventually evolve into HFpEF. Currently, the diagnosis of HFPEF relies mainly on echocardiography. There are no biomarkers that can help diagnose female microvascular disease or facilitate the diagnosis of (early stages of) HFpEF. Recently a Dutch consortium was initiated, Queen of Hearts, with support from the Netherlands Heart Foundation, with the aim to discover and validate biomarkers for diastolic dysfunction and HFpEF in women. These biomarkers come from innovative blood-derived sources such as extracellular vesicles and circulating cells. Within the Queen of Hearts consortium, we will pursue female biomarkers that have the potential for further evolution in assays with point of care capabilities. As a spin-off, the consortium will gain knowledge on gender-specific pathology of HFpEF, possibly opening up novel treatment options.

What Makes for Good Collaboration and Communication in Maternity Care? A Scoping Study

BACKGROUND: Good communication and collaboration are critical to safe care for mothers and babies.

OBJECTIVE: To identify factors associated with good collaboration and communication among maternity care professionals and between both professionals and parents.

METHOD: Scoping study. We searched PubMed and Web of Science for peer reviewed, quantitative and qualitative, original, primary research in Western societies on communication and collaboration in maternity care among professionals (Search 1) and between professionals and parents (Search 2).

FINDINGS: The 40 studies (14 in Search 1; 26 in Search 2) that met our selection criteria highlighted several factors associated with good communication and collaboration. We grouped these factors into 6 categories: Expertise, Partnership, Context, Attitude, Trust, and Communication style. Studies of communication and collaboration among professionals foregrounded work-related aspects, whereas studies examining collaboration between professionals and parents paid more attention to interpersonal aspects. Before 2012, few studies covered positive aspects of communication and collaboration. We also found an underrepresentation of parents in study populations.

CONCLUSION: Our study is part of a growing trend of identifying the positive aspects of communication and collaboration in maternity care. As the study of collaboration in practice continues, researchers need to be sure to involve all stakeholders, including parents.

Smartphone-based analysis of biochemical tests for health monitoring support at home

In the context of home-based healthcare monitoring systems, it is desirable that the results obtained from biochemical tests - tests of various body fluids such as blood and urine - are objective and automatically generated to reduce the number of man-made errors. The authors present the StripTest reader - an innovative smartphone-based interpreter of biochemical tests based on paper-based strip colour using image processing techniques. The working principles of the reader include image acquisition of the colour strip pads using the camera phone, analysing the images within the phone and comparing them with reference colours provided by the manufacturer to obtain the test result. The detection of kidney damage was used as a scenario to illustrate the application of, and test, the StripTest reader. An extensive evaluation using laboratory and human urine samples demonstrates the reader's accuracy and precision of detection, indicating the successful development of a cheap, mobile and smart reader for home-monitoring of kidney functioning, which can facilitate the early detection of health problems and a timely treatment intervention.

Long-Term Risk to Develop Hypertension in Women With Former Preeclampsia: A Longitudinal Pilot Study

INTRODUCTION

Women with former preeclampsia (exPE) develop chronic hypertension 4 times more often than healthy parous controls. Women, destined to develop remote chronic hypertension, had increased left ventricular mass index (LVMI) and diastolic blood pressure (BP) prior to the onset of hypertension as compared to those remaining normotensive. However, longitudinal data on the progress of this increased LVMI in women destined to develop hypertension are lacking.

METHODS

We included 20 women with exPE and 8 parous controls. At both 1- and 14-year postpartum (pp), we performed cardiac ultrasound and determined circulating levels of the metabolic syndrome variables. Of 14-year pp, 7 (35%) former patients had developed chronic hypertension. We compared these 7 former patients with both the 13 former patients who remained normotensive and the 8 parous controls using the Mann-Whitney U test and Kruskal-Wallis analysis.

RESULTS

Women with hypertensive exPE differed from their normotensive counterparts by a higher incidence of early-onset preeclampsia (PE) in their index pregnancy and a higher rate of recurrence in next pregnancies. At 1-year pp, they also had high/normal BP and higher fasting insulin levels. At 14 years pp, the relative left ventricular wall thickness was higher, and the E/A ratio was lower, in the hypertensive group relative to those remaining normotensive.

CONCLUSION

Women with exPE are at increased risk of developing chronic hypertension, when (1) the PE in the index pregnancy had an early-onset and/or recurred in next pregnancies and (2) the 1-year pp. Blood pressure was high normal. We also noticed that at 14 years pp, the hypertensive group showed signs of concentric left ventricular remodeling along with a decreased E/A ratio.

Foley catheter versus vaginal misoprostol: randomized controlled trial (PROBAAT-M study) and systematic review and meta-analysis of literature

OBJECTIVES

To assess effectiveness and safety of Foley catheter versus vaginal misoprostol for term induction of labor.

STUDY DESIGN

This trial randomly allocated women with singleton term pregnancy to 30-mL Foley catheter or 25-μg vaginal misoprostol tablets. Primary outcome was cesarean delivery rate. Secondary outcomes were maternal and neonatal morbidity and time to birth. Additionally, a systematic review was conducted.

RESULTS

Fifty-six women were allocated to Foley catheter, 64 to vaginal misoprostol tablets. Cesarean delivery rates did not differ significantly (25% Foley versus 17% misoprostol; relative risk [RR] 1.46, 95% confidence interval [CI] 0.72 to 2.94), with more cesarean deliveries due to failure to progress in the Foley group (14% versus 3%; RR 4.57, 95% CI 1.01 to 20.64). Maternal and neonatal outcomes were comparable. Time from induction to birth was longer in the Foley catheter group (36 hours versus 25 hours; p < 0.001). Meta-analysis showed no difference in cesarean delivery rate and reduced vaginal instrumental deliveries and hyperstimulation in the Foley catheter group. Other outcomes were not different.

CONCLUSION

Our trial and meta-analysis showed no difference in cesarean delivery rates and less hyperstimulation with fetal heart rate changes and vaginal instrumental deliveries when using Foley catheter, thereby supporting potential advantages of the Foley catheter over misoprostol as ripening agent.

Hypertension after preeclampsia is preceded by changes in cardiac structure and function

Preeclampsia is associated with a 4-fold higher risk for developing remote chronic hypertension. Preeclampsia is accompanied by left ventricular hypertrophy and decreased diastolic function, which may or may not resolve postpartum. We tested the hypothesis that increased measures of cardiac geometry and decreased cardiac function persisting for ≥ 6 months postpartum in normotensive women with a history of preeclampsia precede the development of later chronic hypertension. Formerly preeclamptic women (n=652) underwent echocardiography at 9 months (range, 6-19) postpartum. We excluded women with preexisting hypertension (n=42), hypertension at the postpartum screening (n=133), and those that did not return any checklist (n=128). Eventually, 349 women were included. Remote health was evaluated by a biennially checklist. We used Cox regression for analysis. Twenty-seven (8%) normotensive women had developed chronic hypertension during a medium follow-up period of 6 years. At screening they differed from their counterparts who remained normotensive by hazard ratio for left ventricular mass index (1.11; 95% confidence interval [CI], 1.03-1.18), diastolic blood pressure (1.13; 95% CI, 1.06-1.20), systolic blood pressure (1.07; 95% CI, 1.02-1.11), mean arterial pressure (1.11; 95% CI, 1.05-1.18), heart rate (1.05; 95% CI, 1.01-1.10), and E/A ratio (0.22; 95% CI, 0.06-0.85). Backward stepwise analysis showed independent hazard ratio for left ventricular mass index and diastolic blood pressure 1.08 (95% CI, 1.01-1.16) and 1.13 (95% CI, 1.06-1.21), respectively. In conclusion, the development of later chronic hypertension in initially normotensive formerly preeclamptic women is preceded by increased left ventricular mass index and diastolic blood pressure at postpartum screening.

Cost-effectiveness of induction of labour at term with a Foley catheter compared to vaginal prostaglandin E₂ gel (PROBAAT trial)

OBJECTIVE

To assess the economic consequences of labour induction with Foley catheter compared to prostaglandin E2 gel.

DESIGN

Economic evaluation alongside a randomised controlled trial.

SETTING

Obstetric departments of one university and 11 teaching hospitals in the Netherlands.

POPULATION

Women scheduled for labour induction with a singleton pregnancy in cephalic presentation at term, intact membranes and an unfavourable cervix; and without previous caesarean section.

METHODS

Cost-effectiveness analysis from a hospital perspective.

MAIN OUTCOME MEASURES

We estimated direct medical costs associated with healthcare utilisation from randomisation to 6 weeks postpartum. For caesarean section rate, and maternal and neonatal morbidity we calculated the incremental cost-effectiveness ratios, which represent the costs to prevent one of these adverse outcomes.

RESULTS

Mean costs per woman in the Foley catheter group (n = 411) and in the prostaglandin E₂ gel group (n = 408), were €3297 versus €3075, respectively, with an average difference of €222 (95% confidence interval -€157 to €633). In the Foley catheter group we observed higher costs due to longer labour ward occupation and less cost related to induction material and neonatal admissions. Foley catheter induction showed a comparable caesarean section rate compared with prostaglandin induction, therefore the incremental cost-effectiveness ratio was not informative. Foley induction resulted in fewer neonatal admissions (incremental cost-effectiveness ratio €2708) and asphyxia/postpartum haemorrhage (incremental cost-effectiveness ratios €5257) compared with prostaglandin induction.

CONCLUSIONS

Foley catheter and prostaglandin E2 labour induction generate comparable costs.

OS105. Increased left ventricular mass index in normotensive formerly preeclamptic women is associated with the later development of chronic hypertension

INTRODUCTION

A history of preeclampsia is associated with a 4-fold increased risk to develop chronic hypertension later in life. Interestingly, preeclampsia and chronic hypertension share the presence of increased left ventricular mass and increased left atrial diameter. Whether these increases are also present in the preclinical phase of chronic hypertension in women with a history of preeclampsia is still unknown.

OBJECTIVES

To evaluate whether increased left ventricular mass index and/or left atrial widening in normotensive formerly preeclamptic women are associated with the development of chronic hypertension.

METHODS

324 Women with a history of preeclampsia, who were normotensive at the time of a diagnostic work-up 4 months postpartum, were included in this study. The tests employed included cardiac ultrasound and blood pressure measurements. Left ventricular mass was indexed (LVMi) for length in meters(2.7). To follow up on the health state, we send a health checklist to each screened former patient once every two years. The information of the diagnostic work-up and the one of the returned checklists were used for the statistical analysis by Uni- and Multivariate Cox regression analysis.

RESULTS

Women who had developed chronic hypertension during a medium follow-up period of 6 years showed a significant Hazard Ratio (HR) of 1.11 (95% CI 1.03-1.18) for Left ventricular mass index, 1.13 (95% CI 1.06-1.20) for diastolic BP, 1.07 (95% CI 1.02-1.11) for systolic BP, 1.05 (95% CI 1.01-1.10) for Heart Rate and 0.215 (95% CI 0.055-0.848) for EA ratio. The multivariate top-down analysis showed a significant HR only for LVMi and diastolic BP, 1.08 (95% CI 1.00-1.18) and 1.10 (95% CI 1.02-1.19), respectively.

CONCLUSION

Increased diastolic blood pressure and increased LVMi in normotensive formerly preeclamptic women are both associated with the development of chronic hypertension.