Pregnancy and Heart Disease: Pregnancy-Associated Hypertension and Peripartum Cardiomyopathy

Preeclampsia: A comprehensive review

Preeclampsia (PE) is a life-threatening disease of pregnancy and a prominent cause of neonatal and maternal mortality and morbidity. PE affects approximately 5-10% of pregnancies worldwide, posing significant risks to perinatal and maternal health. It is characterized by a variety of interconnected pathological cascades contributing to the stimulation of intravascular inflammation, oxidative stress (OS), endothelial cell activation, and syncytiotrophoblast stress that converge on a common pathway, ultimately resulting in disease progression. The present study was designed and executed to review the existing scientific literature, specifically focusing on the etiology (gestational diabetes mellitus and maternal obesity, insulin resistance, metabolic syndrome, maternal infection, periodontal disease, altered microbiome, and genetics), clinical presentations (hypertension, blood disorders, proteinuria, hepatic dysfunction, renal dysfunction, pulmonary edema, cardiac dysfunction, fetal growth restrictions, and eclampsia), therapeutic clinical biomarkers (creatinine, albuminuria, and cystatin C) along with their associations and mechanisms in PE. In addition, this study provides insights into the potential of nanomedicines for targeting these mechanisms for PE management and treatment. Inflammation, OS, proteinuria, and an altered microbiome are prominent biomarkers associated with progression and PE-related pathogenesis. Understanding the molecular mechanisms, exploring suitable markers, targeted interventions, comprehensive screening, and holistic strategies are critical to decreasing the incidence of PE and promoting maternal-fetal well-being. The present study comprehensively reviewed the etiology, clinical presentations, therapeutic biomarkers, and preventive potential of nanomedicines in the treatment and management of PE.

Epidemiological features and mortality risk factors of peripartum cardiomyopathy in a group of Sub-Saharan African population

BACKGROUND

Peripartum cardiomyopathy (PPCM) is a rare cause of heart failure occurring during pregnancy. Its prevalence seems more frequent in Africa but its epidemiological, clinical and evolutionary particularities remain unknown. This study aimed to evaluate the epidemiological features and mortality risk factors of PPCM.

MATERIAL AND METHOD

We conducted a retrospective cross-sectional study over 38 months (January 2018 to March 2021) in 3 hospitals in the city of Douala(Cameroon). We included all patients with heart failure between the last month of pregnancy and 5 months after delivery without an identified cause. Were excluded, files not containing data on echocardiography, patients with heart failure without dilation or with LVEF≥ 45% and patients with a history of heart disease of known aetiology. Chi² tests and binary logistic regression were used for data analysis; the survival curve according to Kaplan Meier was drawn for the evolution. The threshold of significance was set at 0.05.

RESULTS

A total of 2102 medical records of women with heart failure were searched. In these records, a total of 59 patients showed signs of peripartum heart failure and only 29 fulfilled the inclusion criteria. From a socio-demographic point of view, the average age was 29 ± 7 years and 51.7% of patients were over 30 years old. Among these patients, 79.3% of patients lived in urban areas and 10.3% of patients had a low socio-economic level. The hospital frequency of PPCM was 1.3%. Clinically, primiparous and pauciparous women were the most affected; the diagnosis was made after more than a month of progression in 65.5% of patients. Dyspnea was present in all patients. In addition, 89.7% of patients had a left ventricular end-diastolic diameter ≥ 62 m, 48.3 % had a left ventricular ejection fraction (LVEF) between 30% and 45%, and 51.7% had an LVEF < 30%. The associated mortality rate was 27.7%. The only prognostic factor independently associated with mortality was age < 30 years.

CONCLUSION

The frequency of PPCM is relatively low in Cameroonian urban settings. Moreover, its diagnosis is generally delayed and it induces high mortality. Its occurrence in a woman under the age of 30 is a factor of poor prognosis.

Early Recognition and Treatment for the Optimal Care of Individuals With Peripartum Cardiomyopathy

Peripartum cardiomyopathy (PPCM) is a life-threatening pregnancy-associated condition that often develops within the last month of pregnancy and up to 5 months postpartum. Although it is uncommon, the incidence in the United States is on the rise, especially among Black individuals. Early recognition and treatment are crucial for long-term health and the recovery of left ventricular ejection fraction. Most people with PPCM will recover with time, but a multidisciplinary team is needed to help with long-term treatment. Informed contraception counseling is also needed to minimize the incidence of subsequent pregnancy before recovery, which could worsen conditions. The purpose of this article is to review PPCM and discuss early recognition and management options, which may minimize complications and improve outcomes.

Case Report: Severe Peripartum Cardiac Disease in Myotonic Dystrophy Type 1

Background

Myotonic dystrophy type 1 (DM1) is a hereditary muscular dystrophy affecting ∼2.1–14.3/100,000 adults. Cardiac manifestations of DM1 include conduction disorders and rarely cardiomyopathies. DM1 increases the risk of obstetric complications, however, little is known about the relationship between pregnancy and cardiomyopathy in DM1 due to disease rarity.

Case

A 23-year-old with DM1 developed cardiomyopathy during pregnancy. Despite initial medical stabilization, she subsequently developed multiple spontaneous coronary artery dissections postpartum, worsening cardiomyopathy and multiorgan failure. She died 5 months postpartum.

Conclusion

Though cardiomyopathy and arterial dissection are both known complications of pregnancy, this case suggests individuals with myotonic dystrophy type 1 may be at heightened risk for cardiac disease during the peripartum period. Physicians caring for women with suspected or proven DM1 should offer counseling and be alerted to the risk of cardiac complications with pregnancy and in the peripartum period. Pregnant and peripartum women with DM1 are likely to benefit from more frequent assessments of cardiac function including echocardiograms and early institution of heart failure management protocols when symptoms of cardiomyopathy present.

Postoperative Curative Effect of Cardiac Surgery Diagnosed by Compressed Sensing Algorithm-Based E-Health CT Image Information and Effect of Baduanjin Exercise on Cardiac Autonomic Nerve Function of Patients

This research was aimed at exploring the effect of CT images reconstructed by optimized compressed sensing algorithm on postoperative diagnosis of patients with hypertensive heart disease and the influence of Baduanjin on cardiac autonomic nerve function. Based on the compressed sensing algorithm, the maximum likelihood expectation maximization algorithm was introduced to optimize it, and the optimization algorithm was established. The optimized algorithm and filtered back projection algorithm (FBP) were compared regarding the root mean squared error (RMSE), peak signal-to-noise ratio (PSNR), and structural similar image metric (SSIM). A total of 126 patients with hypertensive heart disease who underwent CT examination in the hospital were selected as study subjects. According to whether Baduanjin intervention was adopted, patients were divided into observation group (conventional treatment +Baduanjin) and control group (conventional treatment), with 63 patients in each group. The effect of CT examination on postoperative diagnosis was analyzed. Systolic blood pressure (SBP), diastolic blood pressure (DBP), differential pressure (DP), respiratory rate and heart rate (HR), very low-frequency (VLF) power, low-frequency (LF) power, high-frequency (HF) power, total power (TP) of HR variability, and changes in LF/HF of patients before and after treatment were compared. The RMSE of the compressed sensing optimization algorithm (3.28 ± 0.36) was significantly lower than that of the FBP algorithm (9.25 ± 1.03) (P < 0.05). The SSIM and PNSR of the compressed sensing optimization algorithm were (0.87 ± 0.10) and (21.22 ± 1.60) dB, respectively. The SSIM was significantly higher than the FBP algorithm (P < 0.01), and the PNSR was also higher than the FBP algorithm (P < 0.05). The detection rate of CT for pleural effusion was 16 cases (25.40%) higher than 5 cases (7.94%) with TTE (P < 0.01). After treatment, SBP, DBP, HR, LF, VLF, LF/HF, and DP values in the observation group were lower than those in the control group (P < 0.05), and TP and HF were higher than those in the control group (P < 0.05). It suggested that a novel algorithm was established based on compressed sensing algorithm to improve image quality. CT image had important guiding significance for postoperative diagnosis of heart. Baduanjin intervention could improve the integrated function of patient's autonomic nervous system and the regulation ability of the vagus nerve.

[Peripartum cardiomyopathy: A review of the literature]

Peripartum cardiomyopathy is a rare and unpredictable pregnancy-related pathology. Idiopathic cardiomyopathy is characterized by a heart failure secondary to left ventricular systolic dysfunction appearing towards the end of pregnancy or in the months following delivery with a non-specific clinic presentation. Through reviewing previous research, our critical literature review wishes to bring a concise and objective summarize for a better understanding of physiopathology, evocative symptoms and knowing of factors influencing prognosis in order to standardize peripartum management. The treatment remains mainly symptomatic but other promising treatments are still in development. In conclusion, early detection and treatment allow a better cardiac function recovery reducing cardiac transplantation.

Preeclampsia-Pathophysiology and Clinical Presentations: JACC State-of-the-Art Review

Preeclampsia is a hypertensive disorder of pregnancy. It affects 2% to 8% of pregnancies worldwide and causes significant maternal and perinatal morbidity and mortality. Hypertension and proteinuria are the cornerstone of the disease, though systemic organ dysfunction may ensue. The clinical syndrome begins with abnormal placentation with subsequent release of antiangiogenic markers, mediated primarily by soluble fms-like tyrosine kinase-1 (sFlt-1) and soluble endoglin (sEng). High levels of sFlt-1 and sEng result in endothelial dysfunction, vasoconstriction, and immune dysregulation, which can negatively impact every maternal organ system and the fetus. This review comprehensively examines the pathogenesis of preeclampsia with a specific focus on the mechanisms underlying the clinical features. Delivery is the only definitive treatment. Low-dose aspirin is recommended for prophylaxis in high-risk populations. Other treatment options are limited. Additional research is needed to clarify the pathophysiology, and thus, identify potential therapeutic targets for improved treatment and, ultimately, outcomes of this prevalent disease.

The Real Maternal Risks in a Pregnancy: A Structured Review to Enhance Maternal Understanding and Education

This review sought to use high-level published data sources for system knowledge translation, collaborative enhanced maternal education and understanding, and prospective maternal quality and safety care planning. The goal was to answer the following question: What are the short- and long-term maternal risks ("near misses," adverse events, severe morbidity and mortality) associated with pregnancy and childbirth? A structured analysis of the literature (systematic review, meta-analysis, observational case-control cohort), focusing on publications between 2016 and April 2019, was undertaken using the following key word search strategy: maternal, morbidity, mortality, co-morbidities (BMI, fertility, hypertension, cardiac, chronic renal disease, diabetes, mental health, stroke), preconception, antepartum, intrapartum, postpartum, "near miss," and adverse events. Only large cohort database sources with control comparison studies were accepted for inclusion because maternal mortality events are rare. Systematic review and meta-analysis were not undertaken because of the wide clinical scope and the goal of creating an education algorithm tool. For this educational tool, the results were presented in a counselling format that included a control group of common maternal morbidity from a regional maternity cohort (2017) of 54 000 births and published risk estimates for pre-conception, pregnancy-associated comorbidity, pregnancy-onset conditions, long-term maternal health associations, and maternal mortality scenarios. Because issues related to maternal comorbidities are increasing in prevalence, personalized pre-conception education on maternal pregnancy risk estimates needs to be encouraged and available to promote greater understanding. This maternal morbidity and mortality evaluation tool allows for patient-provider review and recognition of the possible leading factors associated with an increased risk of maternal morbidity: pre-conception risks (maternal age >45 years; pre-existing cardiac or hypertensive conditions) and pregnancy-obstetrical risks (gestational hypertension, preeclampsia, eclampsia; caesarean delivery, whether preterm or term; operative vaginal delivery; maternal sepsis; placenta accreta spectrum; and antepartum or postpartum hemorrhage).

Angiotensin II receptor blocker LCZ696 attenuates cardiac remodeling through the inhibition of the ERK signaling pathway in mice with pregnancy-associated cardiomyopathy

Pregnancy-associated cardiomyopathy (PAH) represents a pregnancy-associated myocardial disease that is characterized by the progression of heart failure due to marked left ventricular systolic dysfunction. Compelling evidence has highlighted the potential of angiotensin (Ang) receptor inhibitors as therapeutic targets in PAH treatment. The present study aims to elucidate the molecular mechanisms underlying Ang II receptor inhibitor LCZ696 treatment in PAH. Initially, a PAH mouse model was induced, followed by intraperitoneal injection of LCZ696. Subsequently, cardiomyocytes and fibroblasts were isolated, cultured, and treated with Ang II and LCZ696, followed by detection of the total survival rate, cardiac injury, cardiac fibrosis and apoptosis. Moreover, in order to quantify the cardiac hypertrophy and fibrosis degree of cardiac fibroblasts, the expression levels of markers of cardiac hypertrophy (ANP, βMHC and TIMP2) and markers of fibrosis (collagen I, collagen III and TGF-β) were evaluated. Furthermore, the potential effect of LCZ696 on the extracellular signal-regulated kinase (ERK) signaling pathway was examined. The acquired findings revealed that LCZ696 increased the total survival rate of PAH mice, but decreased cardiac injury, cardiac fibrosis, and apoptosis in vitro. LCZ696 attenuated cardiac injury induced by Ang II through the inhibition the expression of markers of cardiac hypertrophy, fibrosis and apoptosis by inhibiting ERK phosphorylation in vivo and in vitro. Altogether, LCZ676 could potentially alleviate cardiac remodeling in mice with PAH via blockade of the ERK signaling pathway activation. Our findings suggest that LCZ696 could be a potential target for PAH therapy.

Peripartum Cardiomyopathy: A Review

PURPOSE OF REVIEW

Peripartum cardiomyopathy (PPCM) is an important condition with high morbidity and mortality worldwide. Patients with PPCM are at risk of developing life-long cardiac disease, requiring regular management and medical intervention. This article conducts a review of recent literature and gives insight into this disease.

RECENT FINDINGS

There is promising research in the fields of vascular, hormonal and genetics. A number of genetic markers are being analyzed; including TTNC1, TTN and STAT3. Mutations to these genes have been found to be prevalent in PPCM. These combined with the secretion of placental angiogenic factors potentially create imbalance in angiogenesis as the primary etiology.

SUMMARY

Current biomarkers do not differentiate between PPCM and other variants of heart failure. Women with PPCM are more likely to have a cesarean section, have hypertensive disease, at greater risk of major adverse cardiac events and to have lifelong morbidity.