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Rosół N, Procyk G, Kacperczyk-Bartnik J, Grabowski M, Gąsecka A. N-terminal prohormone of brain natriuretic peptide in gestational hypertension and preeclampsia - State of the art. Eur J Obstet Gynecol Reprod Biol 2024; 297:96-105. [PMID: 38603986 DOI: 10.1016/j.ejogrb.2024.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 03/04/2024] [Accepted: 04/07/2024] [Indexed: 04/13/2024]
Abstract
N-terminal prohormone of brain natriuretic peptide (NT-proBNP) is a non-active prohormone secreted by ventricular cardiomyocytes into the circulation in response to ventricle overload, mainly due to increased blood volume. The changes in NT-proBNP levels during pregnancy have been investigated in multiple studies. In the case of hypertensive disorders of pregnancy, increased vasoconstriction leads to increased blood pressure and afterload. Together with the volume overload of pregnancy, it leads to higher NT-proBNP secretion. As hypertensive disorders of pregnancy are among the leading causes of prematurity and perinatal mortality, early prediction and diagnosis of gestational hypertension, and preeclampsia are essential for improving maternal and infant prognosis. NT-proBNP has been regarded as a potential biomarker of hypertensive disorders of pregnancy. In this review, we have thoroughly summarized the current data on the prognostic and diagnostic utility of NT-proBNP in patients with gestational hypertension and preeclampsia. NT-proBNP values may help distinguish between non-preeclamptic and preeclamptic patients, even if there are no significant differences in blood pressure. Moreover, in pregnancies complicated by preeclampsia, the value of increased NT-proBNP level is related to the stage and the severity of the disease. Further improvement of our knowledge about NT-proBNP as a diagnostic biomarker and a putative predictor of adverse cardiac events in women with hypertensive disorders of pregnancy should lead to better management of these patients.
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Affiliation(s)
- Natalia Rosół
- 2nd Department of Obstetrics and Gynecology, Medical University of Warsaw, Karowa 2, 00-315 Warsaw, Poland.
| | - Grzegorz Procyk
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Banacha 1A, 02-097 Warsaw, Poland.
| | - Joanna Kacperczyk-Bartnik
- 2nd Department of Obstetrics and Gynecology, Medical University of Warsaw, Karowa 2, 00-315 Warsaw, Poland.
| | - Marcin Grabowski
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Banacha 1A, 02-097 Warsaw, Poland.
| | - Aleksandra Gąsecka
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Banacha 1A, 02-097 Warsaw, Poland.
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2
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Schuermans A, Truong B, Ardissino M, Bhukar R, Slob EAW, Nakao T, Dron JS, Small AM, Cho SMJ, Yu Z, Hornsby W, Antoine T, Lannery K, Postupaka D, Gray KJ, Yan Q, Butterworth AS, Burgess S, Wood MJ, Scott NS, Harrington CM, Sarma AA, Lau ES, Roh JD, Januzzi JL, Natarajan P, Honigberg MC. Genetic Associations of Circulating Cardiovascular Proteins With Gestational Hypertension and Preeclampsia. JAMA Cardiol 2024; 9:209-220. [PMID: 38170504 PMCID: PMC10765315 DOI: 10.1001/jamacardio.2023.4994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 11/01/2023] [Indexed: 01/05/2024]
Abstract
Importance Hypertensive disorders of pregnancy (HDPs), including gestational hypertension and preeclampsia, are important contributors to maternal morbidity and mortality worldwide. In addition, women with HDPs face an elevated long-term risk of cardiovascular disease. Objective To identify proteins in the circulation associated with HDPs. Design, Setting, and Participants Two-sample mendelian randomization (MR) tested the associations of genetic instruments for cardiovascular disease-related proteins with gestational hypertension and preeclampsia. In downstream analyses, a systematic review of observational data was conducted to evaluate the identified proteins' dynamics across gestation in hypertensive vs normotensive pregnancies, and phenome-wide MR analyses were performed to identify potential non-HDP-related effects associated with the prioritized proteins. Genetic association data for cardiovascular disease-related proteins were obtained from the Systematic and Combined Analysis of Olink Proteins (SCALLOP) consortium. Genetic association data for the HDPs were obtained from recent European-ancestry genome-wide association study meta-analyses for gestational hypertension and preeclampsia. Study data were analyzed October 2022 to October 2023. Exposures Genetic instruments for 90 candidate proteins implicated in cardiovascular diseases, constructed using cis-protein quantitative trait loci (cis-pQTLs). Main Outcomes and Measures Gestational hypertension and preeclampsia. Results Genetic association data for cardiovascular disease-related proteins were obtained from 21 758 participants from the SCALLOP consortium. Genetic association data for the HDPs were obtained from 393 238 female individuals (8636 cases and 384 602 controls) for gestational hypertension and 606 903 female individuals (16 032 cases and 590 871 controls) for preeclampsia. Seventy-five of 90 proteins (83.3%) had at least 1 valid cis-pQTL. Of those, 10 proteins (13.3%) were significantly associated with HDPs. Four were robust to sensitivity analyses for gestational hypertension (cluster of differentiation 40, eosinophil cationic protein [ECP], galectin 3, N-terminal pro-brain natriuretic peptide [NT-proBNP]), and 2 were robust for preeclampsia (cystatin B, heat shock protein 27 [HSP27]). Consistent with the MR findings, observational data revealed that lower NT-proBNP (0.76- to 0.88-fold difference vs no HDPs) and higher HSP27 (2.40-fold difference vs no HDPs) levels during the first trimester of pregnancy were associated with increased risk of HDPs, as were higher levels of ECP (1.60-fold difference vs no HDPs). Phenome-wide MR analyses identified 37 unique non-HDP-related protein-disease associations, suggesting potential on-target effects associated with interventions lowering HDP risk through the identified proteins. Conclusions and Relevance Study findings suggest genetic associations of 4 cardiovascular disease-related proteins with gestational hypertension and 2 associated with preeclampsia. Future studies are required to test the efficacy of targeting the corresponding pathways to reduce HDP risk.
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Affiliation(s)
- Art Schuermans
- Program in Medical and Population Genetics and Cardiovascular Disease Initiative, Broad Institute of Harvard and MIT, Cambridge, Massachusetts
- Cardiovascular Research Center, Massachusetts General Hospital, Boston
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Buu Truong
- Program in Medical and Population Genetics and Cardiovascular Disease Initiative, Broad Institute of Harvard and MIT, Cambridge, Massachusetts
- Cardiovascular Research Center, Massachusetts General Hospital, Boston
| | - Maddalena Ardissino
- BHF Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Rohan Bhukar
- Program in Medical and Population Genetics and Cardiovascular Disease Initiative, Broad Institute of Harvard and MIT, Cambridge, Massachusetts
- Cardiovascular Research Center, Massachusetts General Hospital, Boston
| | - Eric A. W. Slob
- MRC Biostatistics Unit, University of Cambridge, Cambridge, United Kingdom
- Department of Applied Economics, Erasmus School of Economics, Erasmus University Rotterdam, Rotterdam, the Netherlands
- Erasmus University Rotterdam Institute for Behavior and Biology, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - Tetsushi Nakao
- Program in Medical and Population Genetics and Cardiovascular Disease Initiative, Broad Institute of Harvard and MIT, Cambridge, Massachusetts
- Cardiovascular Research Center, Massachusetts General Hospital, Boston
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Jacqueline S. Dron
- Program in Medical and Population Genetics and Cardiovascular Disease Initiative, Broad Institute of Harvard and MIT, Cambridge, Massachusetts
- Cardiovascular Research Center, Massachusetts General Hospital, Boston
| | - Aeron M. Small
- Program in Medical and Population Genetics and Cardiovascular Disease Initiative, Broad Institute of Harvard and MIT, Cambridge, Massachusetts
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - So Mi Jemma Cho
- Program in Medical and Population Genetics and Cardiovascular Disease Initiative, Broad Institute of Harvard and MIT, Cambridge, Massachusetts
- Cardiovascular Research Center, Massachusetts General Hospital, Boston
- Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Zhi Yu
- Program in Medical and Population Genetics and Cardiovascular Disease Initiative, Broad Institute of Harvard and MIT, Cambridge, Massachusetts
- Cardiovascular Research Center, Massachusetts General Hospital, Boston
| | - Whitney Hornsby
- Program in Medical and Population Genetics and Cardiovascular Disease Initiative, Broad Institute of Harvard and MIT, Cambridge, Massachusetts
- Cardiovascular Research Center, Massachusetts General Hospital, Boston
| | - Tajmara Antoine
- Program in Medical and Population Genetics and Cardiovascular Disease Initiative, Broad Institute of Harvard and MIT, Cambridge, Massachusetts
- Cardiovascular Research Center, Massachusetts General Hospital, Boston
| | - Kim Lannery
- Program in Medical and Population Genetics and Cardiovascular Disease Initiative, Broad Institute of Harvard and MIT, Cambridge, Massachusetts
- Cardiovascular Research Center, Massachusetts General Hospital, Boston
| | - Darina Postupaka
- Program in Medical and Population Genetics and Cardiovascular Disease Initiative, Broad Institute of Harvard and MIT, Cambridge, Massachusetts
- Cardiovascular Research Center, Massachusetts General Hospital, Boston
| | - Kathryn J. Gray
- Division of Maternal-Fetal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Qi Yan
- Department of Obstetrics and Gynecology, Columbia University, New York, New York
| | - Adam S. Butterworth
- BHF Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
- BHF Centre of Research Excellence, University of Cambridge, Cambridge, United Kingdom
- National Institute for Health Research Cambridge Biomedical Research Centre, University of Cambridge and Cambridge University Hospitals, Cambridge, United Kingdom
- Health Data Research UK Cambridge, Wellcome Genome Campus and University of Cambridge, Cambridge, United Kingdom
- National Institute for Health Research Blood and Transplant Research Unit in Donor Health and Genomics, University of Cambridge, Cambridge, United Kingdom
| | - Stephen Burgess
- MRC Biostatistics Unit, University of Cambridge, Cambridge, United Kingdom
| | - Malissa J. Wood
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Cardiology Division, Massachusetts General Hospital, Boston
- Lee Health, Fort Myers, Florida
| | - Nandita S. Scott
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Cardiology Division, Massachusetts General Hospital, Boston
| | - Colleen M. Harrington
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Cardiology Division, Massachusetts General Hospital, Boston
| | - Amy A. Sarma
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Cardiology Division, Massachusetts General Hospital, Boston
| | - Emily S. Lau
- Cardiovascular Research Center, Massachusetts General Hospital, Boston
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Cardiology Division, Massachusetts General Hospital, Boston
| | - Jason D. Roh
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Cardiology Division, Massachusetts General Hospital, Boston
| | - James L. Januzzi
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Cardiology Division, Massachusetts General Hospital, Boston
- Baim Institute for Clinical Research, Boston, Massachusetts
| | - Pradeep Natarajan
- Program in Medical and Population Genetics and Cardiovascular Disease Initiative, Broad Institute of Harvard and MIT, Cambridge, Massachusetts
- Cardiovascular Research Center, Massachusetts General Hospital, Boston
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Cardiology Division, Massachusetts General Hospital, Boston
| | - Michael C. Honigberg
- Program in Medical and Population Genetics and Cardiovascular Disease Initiative, Broad Institute of Harvard and MIT, Cambridge, Massachusetts
- Cardiovascular Research Center, Massachusetts General Hospital, Boston
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Cardiology Division, Massachusetts General Hospital, Boston
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Fixler JS, Byrne JJ, Mcintire DD, Nelson DB, Gary Cunningham F. Intrapartum trends of NT-proBNP and hs-cTnT in patients with severe features of preeclampsia. Pregnancy Hypertens 2024; 35:1-5. [PMID: 38029452 DOI: 10.1016/j.preghy.2023.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 11/13/2023] [Accepted: 11/16/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND Preeclampsia with severe features (SPE) is a multisystem syndrome associated with long-term cardiovascular morbidity. Serum concentrations of N-terminal B-type natriuretic peptide (NT-proBNP) and high sensitivity cardiac troponin-T (hs-cTnT) are sensitive markers of cardiac stretch and ischemia, respectively. OBJECTIVE Our aim was to examine NT-proBNP and hs-cTnT in patients with SPE during labor. We hypothesized that patients with severe preeclampsia would have increased serum concentrations of these analytes as compared with normotensive laboring patients. STUDY DESIGN This was a prospective cohort study of intrapartum patients with SPE and normotensive controls. Patients were recruited at the time of SPE diagnosis or admission to the labor unit, and those with medical conditions that could predispose to baseline cardiac dysfunction were excluded. Serum from venous blood was collected for NT-proBNP and hs-cTnT measurement at three time points: 0-2 h, 4 h, and 12 h after admission. A mixed random effects regression model was used to compare analyte levels at each time point and to compare trends over time. The primary outcome was NT-proBNP concentration at each collection time point in patients with severe preeclampsia as compared to normotensive controls. Power analysis yielded a goal sample of 25 patients with a 12 h and at least 1 other sample in each arm. Two-tailed P values less than 0.05 were considered statistically significant. P value adjustment for multiple comparisons was performed. RESULTS Of 78 patients analyzed, 36 had severe preeclampsia and 42 were normotensive controls with 25 in each cohort having a 12 h and at least 1 other sample. The NT-proBNP trend was significantly different in the two cohorts (P < 0.001). After adjustment for multiple comparisons, the mean serum concentration of NT-proBNP was elevated in the severe preeclampsia group at 0-2 and 4 h, but not at 12 h. After similar adjustment, detectable serum concentrations of hs-cTnT were more frequent in patients with severe preeclampsia at all three timepoints. CONCLUSION Intrapartum serum concentrations of NT-proBNP were elevated nearly twofold in patients with SPE when compared with normotensive controls, with the most pronounced differences found during early labor. Detectable but low serum concentrations of hs-cTnT were more common in women with severe preeclampsia as compared with normotensive controls. These findings suggest cardiac dysfunction with SPE may be present at the time of admission and contribute to features of maternal cardiovascular morbidity and mortality.
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Affiliation(s)
- Joseph S Fixler
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
| | - John J Byrne
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Texas Health Science Center, San Antonio, TX, USA
| | - Donald D Mcintire
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Texas Southwestern, Dallas, TX, USA
| | - David B Nelson
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Texas Southwestern, Dallas, TX, USA
| | - F Gary Cunningham
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Texas Southwestern, Dallas, TX, USA
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Mortensen SM, Ekelund CK, Pedersen BW, Tabor A, Rode L. Lack of an association between first-trimester concentration of mid-regional pro-atrial natriuretic peptide and risk of early-onset preeclampsia <34 weeks' gestation. J Obstet Gynaecol Res 2023. [PMID: 37300367 DOI: 10.1111/jog.15700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 05/15/2023] [Indexed: 06/12/2023]
Abstract
AIM We examined the heart failure biomarker mid-regional pro-atrial natriuretic peptide during the first trimester of pregnancy in relation to early-onset preeclampsia <34 weeks. MATERIALS AND METHODS This case-control study included 34 women with singleton pregnancies with a preeclampsia diagnosis and delivery before 34 weeks of gestation who had attended the routine first-trimester ultrasound scan at 11-13+6 weeks of gestation between August 2010 and October 2015 at the Copenhagen University Hospital Rigshospitalet, Denmark, and 91 uncomplicated singleton pregnancies matched by time of the routine first-trimester blood sampling at 8-13+6 weeks. Descriptive statistical analyses were performed for maternal characteristics and obstetric and medical history for the case versus the control group. Concentrations of mid-regional pro-atrial natriuretic peptide, placental growth factor, soluble fms-like tyrosine kinase-1, and pregnancy-associated plasma protein A between early-onset preeclampsia cases and the control group were compared using Students t-test and the Mann-Whitney U test. Biochemical marker concentrations were converted into multiples of the expected median values after adjustment for gestational age. RESULTS Mid-regional pro-atrial natriuretic peptide levels were not significantly different between early-onset preeclampsia cases and the control group in the first trimester of pregnancy. As expected, both placental growth factor and pregnancy-associated plasma protein A levels were significantly lower in early-onset preeclampsia, whereas soluble fms-like tyrosine kinase-1 levels were not statistically significantly different. CONCLUSION The maternal first-trimester concentration of mid-regional pro-atrial natriuretic peptide, a peptide with multiple biological functions including a relation to cardiovascular disease, was not significantly different in women with early-onset preeclampsia.
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Affiliation(s)
- Signe Milling Mortensen
- Center of Fetal Medicine and Pregnancy, Department of Obstetrics, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Charlotte Kvist Ekelund
- Center of Fetal Medicine and Pregnancy, Department of Obstetrics, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Berit Woetmann Pedersen
- Department of Obstetrics, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Ann Tabor
- Center of Fetal Medicine and Pregnancy, Department of Obstetrics, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Line Rode
- Center of Fetal Medicine and Pregnancy, Department of Obstetrics, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Biochemistry, Copenhagen University Hospital Rigshospitalet, Glostrup, Denmark
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Assessing maternal cardiac function by obstetricians: technique and reference ranges. Am J Obstet Gynecol 2023:S0002-9378(23)00006-6. [PMID: 36627073 DOI: 10.1016/j.ajog.2023.01.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 12/30/2022] [Accepted: 01/03/2023] [Indexed: 01/09/2023]
Abstract
BACKGROUND A strong body of evidence has now coalesced indicating that some obstetrical syndromes may result from maladaptive responses of the maternal cardiovascular system. Longitudinal studies have shown that these changes are complex and present before the clinical recognition of preeclampsia and fetal growth restriction, suggesting that hemodynamic maladaptation may play an etiologic role in obstetrical complications. Chronic hypertension is one of the most frequent complications of pregnancy, and recent evidence suggests that control of mild hypertension in early pregnancy improves outcome. The management of chronic hypertension can be improved by understanding specific cardiovascular hemodynamic abnormalities such as increased cardiac output or increased systemic vascular resistance, which can respond to either beta or calcium channel blockers, depending on the hemodynamic findings. Evaluation of maternal cardiac function has not been previously available to obstetrical healthcare providers using diagnostic ultrasound equipment used for fetal evaluation. OBJECTIVE Obstetrical ultrasound machines may be configured for various probes (endovaginal, abdominal, 3D/4D, and cardiac). This study used a cardiac probe placed in the suprasternal notch to image and measure the descending aorta diameter and the velocity time integral using pulsed and continuous wave Doppler ultrasound in normal pregnant women between 11 and 39 weeks of gestation. These measurements were followed by computation of maternal left ventricular preload, afterload, contractility, and blood flow. STUDY DESIGN This was a prospective cross-sectional study. A total of 400 pregnant women were recruited between 11 and 39 weeks of gestation. Imaging of the maternal aortic arch was performed by placing a cardiac probe in the suprasternal notch to identify the aortic arch using 2D and color Doppler ultrasound. The end-systolic diameter of the aorta was measured at the junction of the left subclavian artery with the descending aorta, which was followed by insonation of the descending aorta to obtain the Doppler waveform. Following insonation of the descending aorta, measurements of the aortic diameter, velocity time integral, ejection time, mean pressure gradient, heart rate, maternal weight and height, and systolic and diastolic blood pressures were entered into an Excel spreadsheet to compute the following: (1) preload measurements of stroke volume, stroke volume index, and stroke work index; (2) afterload measurements of systemic vascular resistance and the potential-to-kinetic energy ratio; (3) contractility measurements of inotropy and the Smith-Madigan inotropy index; and (4) blood flow measurements of cardiac output and the cardiac output index. Fractional polynomial regression analysis was performed for each of the above measurements using gestational age as the independent variable. RESULTS The diastolic and mean arterial blood pressure decreased from 11 to 18 weeks of gestation and then increased until term. The afterload measurements demonstrated similar characteristics, as all values decreased from 11 weeks until the mid and late second trimester, after which all values increased until term. Changes in contractility demonstrated an increase from 11 weeks to 25 to 28 weeks, followed by a decline until term. Changes in blood flow demonstrated an increase from 11 to 27 weeks and then declined until term. The continuous wave Doppler values were greater than the pulsed Doppler values except for the contractility measurements. Examples of abnormal cardiac measurements were identified in pregnant patients with hypertension and fetal growth restriction. An Excel calculator was created to provide quick computation of z-score measurements and their corresponding centiles described in this study. CONCLUSION The technique for evaluation of maternal cardiac function described in this study would allow screening of maternal left ventricular preload, afterload, contractility, and blood flow in the obstetrical clinical milieu once a cardiac probe is acquired for obstetrical ultrasound machines used for fetal evaluation. The above measurements would allow the clinician to select appropriate hypertensive medication on the basis of the results of the evaluation of the maternal left ventricle.
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Malhamé I, Dong S, Syeda A, Ashraf R, Zipursky J, Horn D, Daskalopoulou SS, D'Souza R. The use of loop diuretics in the context of hypertensive disorders of pregnancy: a systematic review and meta-analysis. J Hypertens 2023; 41:17-26. [PMID: 36453652 DOI: 10.1097/hjh.0000000000003310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
AIMS Addressing volume expansion may improve the management of hypertension across the pregnancy continuum. We conducted a systematic review to summarize the evidence on the use of loop diuretics in the context of hypertensive disorders during pregnancy and the postpartum period. METHODS AND RESULTS Medline, Embase, Cochrane library, ClinicalTrials.gov, and Google Scholar were searched for original research articles published up to 29 June 2021. Of the 2801 results screened, 15 studies were included: eight randomized controlled trials, six before-after studies, and one cohort study. Based on random effects meta-analysis of before-after studies, antepartum use of loop diuretics was associated with lower DBP [mean difference -17.73 mmHg, (95% confidence intervals -34.50 to -0.96); I2 = 94%] and lower cardiac output [mean difference -0.75 l/min, (-1.11 to -0.39); I2 = 0%], with no difference in SBP, mean arterial pressure, heart rate, or total peripheral resistance. Meta-analysis of randomized controlled trials revealed that postpartum use of loop diuretics was associated with decreased need for additional antihypertensive patients [relative risk 0.69, (0.50-0.97); I2 = 14%], and an increased duration of hospitalization [mean difference 8.80 h, (4.46-13.14); I2 = 83%], with no difference in the need for antihypertensive therapy at hospital discharge, or persistent postpartum hypertension. CONCLUSION Antepartum use of loop diuretics lowered DBP and cardiac output, while their postpartum use reduced the need for additional antihypertensive medications. There was insufficient evidence to suggest a clear benefit. Future studies focusing on women with hypertensive pregnancy disorders who may most likely benefit from loop diuretics are required.
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Affiliation(s)
- Isabelle Malhamé
- Department of Medicine, McGill University Health Centre
- Research Institute of the McGill University Health Centre, Montréal, Quebéc
| | - Susan Dong
- Faculty of Medicine, University of Toronto
| | - Ambreen Syeda
- Department of Obstetrics & Gynaecology, Mount Sinai Hospital, Toronto
| | - Rizwana Ashraf
- Department of Obstetrics & Gynaecology, Mount Sinai Hospital, Toronto
- Department of Obstetrics & Gynaecology, McMaster University, Hamilton
| | - Jonathan Zipursky
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto
- Institute of Health Policy, Management, and Evaluation, University of Toronto
| | - Daphne Horn
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Stella S Daskalopoulou
- Department of Medicine, McGill University Health Centre
- Research Institute of the McGill University Health Centre, Montréal, Quebéc
| | - Rohan D'Souza
- Department of Obstetrics & Gynaecology, Mount Sinai Hospital, Toronto
- Department of Obstetrics & Gynaecology, McMaster University, Hamilton
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7
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Eroğlu H, Erdöl MA, Tonyalı NV, Örgül G, Biriken D, Yücel A, Yazihan N, Şahin D. Maternal Serum and Umbilical Cord Brain Natriuretic Peptide Levels in Fetuses with Intrauterine Growth Restriction. Fetal Pediatr Pathol 2022; 41:722-730. [PMID: 34311665 DOI: 10.1080/15513815.2021.1955057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Aim: We compared maternal serum and fetal cord blood proBNP levels in healthy pregnancies to those with intrauterine growth restriction (IUGR). Methods: Prospectively, maternal and cord blood samples at childbirth of 40 pregnant women with isolated IUGR and 40 healthy pregnant women were evaluated for ProBNP levels. Results: The mean serum ProBNP level was significantly higher in newborn cord blood with IUGR than in the control group (181.28 ± 145.37 vs. 91.41 ± 49.77 pg/mL, p = <0.01). Mean serum ProBNP level trended higher in women with IUGR compared to the controls, but was not statistically significant (124.21 ± 113.32 vs. 88.73 ± 85.18 pg/mL, p= >0.05). Conclusion: Third trimester mean proBNP in fetal cord blood are increased in IUGR fetuses at term birth compared to pregnancies with normal fetal growth.
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Affiliation(s)
- Hasan Eroğlu
- Etlik Zübeyde Hanım Maternity and Women's Health Teaching and Research Hospital, Ankara, Turkey
| | | | - Nazan Vanlı Tonyalı
- Etlik Zübeyde Hanım Maternity and Women's Health Teaching and Research Hospital, Ankara, Turkey
| | - Gökçen Örgül
- Etlik Zübeyde Hanım Maternity and Women's Health Teaching and Research Hospital, Ankara, Turkey
| | - Derya Biriken
- Faculty of Medicine, Department of Microbiology, Ankara University, Ankara, Turkey
| | - Aykan Yücel
- Etlik Zübeyde Hanım Maternity and Women's Health Teaching and Research Hospital, Ankara, Turkey
| | - Nuray Yazihan
- Faculty of Medicine, Department of Pathophysiology, Ankara University, Ankara, Turkey
| | - Dilek Şahin
- Etlik Zübeyde Hanım Maternity and Women's Health Teaching and Research Hospital, Ankara, Turkey
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8
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Sarma AA, Aggarwal NR, Briller JE, Davis M, Economy KE, Hameed AB, Januzzi JL, Lindley KJ, Mattina DJ, McBay B, Quesada O, Scott NS. The Utilization and Interpretation of Cardiac Biomarkers During Pregnancy: JACC: Advances Expert Panel. JACC. ADVANCES 2022; 1:100064. [PMID: 38938393 PMCID: PMC11198183 DOI: 10.1016/j.jacadv.2022.100064] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 07/04/2022] [Accepted: 07/06/2022] [Indexed: 06/29/2024]
Abstract
Cardiac biomarkers are widely used in the nonpregnant population when acute cardiovascular (CV) pathology is suspected; however, the behavior of these biomarkers in the context of pregnancy is less well understood. Pregnant individuals often have symptoms that mimic those of cardiac dysfunction, and complications of pregnancy may include CV disease. This paper will summarize our current knowledge on the use of cardiac biomarkers in pregnancy and provide suggestions on how to use these tools in clinical practice based on the available evidence. Natriuretic peptides and troponin should not be measured routinely in uncomplicated pregnancy, where values should remain low as in the nonpregnant population. In the context of pre-existing or suspected CV disease, these biomarkers retain their negative predictive value. Elevations of both natriuretic peptides and troponin may occur without clear clinical significance in the immediate postpartum period. Elevations of these markers should always prompt further investigation into possible CV pathology.
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Affiliation(s)
- Amy A. Sarma
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Niti R. Aggarwal
- Department of Cardiovascular diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Joan E. Briller
- Division of Cardiology, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Melinda Davis
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Katherine E. Economy
- Harvard Medical School, Boston, Massachusetts, USA
- Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | | | - James L. Januzzi
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Baim Institute for Clinical Research, Boston, Massachusetts, USA
| | - Kathryn J. Lindley
- Cardiovascular Division, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Deirdre J. Mattina
- Division of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Brandon McBay
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Odayme Quesada
- Women’s Heart Center, The Christ Hospital Heart and Vascular Institute, Cincinnati, Ohio, USA
- The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, Cincinnati, Ohio, USA
| | - Nandita S. Scott
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - American College of Cardiology Cardiovascular Disease in Women Committee and Cardio-obstetrics Work Group
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Cardiovascular diseases, Mayo Clinic, Rochester, Minnesota, USA
- Division of Cardiology, University of Illinois at Chicago, Chicago, Illinois, USA
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Brigham and Women’s Hospital, Boston, Massachusetts, USA
- University of California, Irvine, Orange, California, USA
- Baim Institute for Clinical Research, Boston, Massachusetts, USA
- Cardiovascular Division, Washington University in St. Louis, St. Louis, Missouri, USA
- Division of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
- Women’s Heart Center, The Christ Hospital Heart and Vascular Institute, Cincinnati, Ohio, USA
- The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, Cincinnati, Ohio, USA
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9
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Giannubilo SR, Amici M, Pizzi S, Simonini A, Ciavattini A. Maternal hemodynamics and computerized cardiotocography during labor with epidural analgesia. Arch Gynecol Obstet 2022; 307:1789-1794. [PMID: 35704115 PMCID: PMC10147743 DOI: 10.1007/s00404-022-06658-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 06/01/2022] [Indexed: 11/02/2022]
Abstract
PURPOSE To analyze the mechanisms involved in the fetal heart rate (FHR) abnormalities after the epidural analgesia in labor. METHODS A prospective unblinded single-center observational study on 55 term singleton pregnant women with spontaneous labor. All women recruited underwent serial bedside measurements of the main hemodynamic parameters using a non-invasive ultrasound system (USCOM-1A). Total vascular resistances (TVR), heart rate (HR), stroke volume (SV), cardiac output (CO) and arterial blood pressure were measured before epidural administration (T0), after 5 min 5 (T1) from epidural bolus and at the end of the first stage of labor (T2). FHR was continuously recorded through computerized cardiotocography before and after the procedure. RESULTS The starting CO was significantly higher in a subgroup of women with low TVR than in women with high-TVR group. After the bolus of epidural analgesia in the low-TVR group there was a significant reduction in CO and then increased again at the end of the first stage, in the high-TVR group the CO increased insignificantly after the anesthesia bolus, while it increased significantly in the remaining part of the first stage of labor. On the other hand, CO was inversely correlated with the number of decelerations detected on cCTG in the 1 hour after the epidural bolus while the short-term variation was significantly lower in the group with high-TVR. CONCLUSION Maternal hemodynamic status at the onset of labor can make a difference in fetal response to the administration of epidural analgesia.
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Affiliation(s)
- Stefano Raffaele Giannubilo
- Department of Obstetrics and Gynecology, Marche Polytechnic University, Ancona, Italy. .,Department of Clinical Sciences, Polytechnic University of Marche Salesi Hospital, via Corridoni 11, 60123, Ancona, Italy.
| | - Mirco Amici
- Department of Anaesthesia and Intensive Care, Salesi Hospital, Ancona, Italy
| | - Simone Pizzi
- Department of Anaesthesia and Intensive Care, Salesi Hospital, Ancona, Italy
| | - Alessandro Simonini
- Department of Anaesthesia and Intensive Care, Salesi Hospital, Ancona, Italy
| | - Andrea Ciavattini
- Department of Clinical Sciences, Polytechnic University of Marche Salesi Hospital, via Corridoni 11, 60123, Ancona, Italy
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10
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Ullmo J, Cruz-Lemini M, Sánchez-García O, Bos-Real L, Fernandez De La Llama P, Calero F, Domínguez-Gallardo C, Garrido-Gimenez C, Trilla C, Carreras-Costa F, Sionis A, Mora J, García-Osuna Á, Ordoñez-Llanos J, Llurba E. Cardiac dysfunction and remodeling regulated by anti-angiogenic environment in patients with preeclampsia: the ANGIOCOR prospective cohort study protocol. BMC Pregnancy Childbirth 2021; 21:816. [PMID: 34879854 PMCID: PMC8653611 DOI: 10.1186/s12884-021-04263-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 11/10/2021] [Indexed: 11/16/2022] Open
Abstract
Background Cardiovascular diseases (CVD) are cause of increased morbidity and mortality in spite of advances for diagnosis and treatment. Changes during pregnancy affect importantly the maternal CV system. Pregnant women that develop preeclampsia (PE) have higher risk (up to 4 times) of clinical CVD in the short- and long-term. Predominance of an anti-angiogenic environment during pregnancy is known as main cause of PE, but its relationship with CV complications is still under research. We hypothesize that angiogenic factors are associated to maternal cardiac dysfunction/remodeling and that these may be detected by new cardiac biomarkers and maternal echocardiography. Methods Prospective cohort study of pregnant women with high-risk of PE in first trimester screening, established diagnosis of PE during gestation, and healthy pregnant women (total intended sample size n = 440). Placental biochemical and biophysical cardiovascular markers will be assessed in the first and third trimesters of pregnancy, along with maternal echocardiographic parameters. Fetal cardiac function at third trimester of pregnancy will be also evaluated and correlated with maternal variables. Maternal cardiac function assessment will be determined 12 months after delivery, and correlation with CV and PE risk variables obtained during pregnancy will be evaluated. Discussion The study will contribute to characterize the relationship between anti-angiogenic environment and maternal CV dysfunction/remodeling, during and after pregnancy, as well as its impact on future CVD risk in patients with PE. The ultimate goal is to improve CV health of women with high-risk or previous PE, and thus, reduce the burden of the disease. Trial registration NCT04162236
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Affiliation(s)
- Johana Ullmo
- Obstetrics and Gynecology Department, Santa Creu i Sant Pau University Hospital & Universitat Autònoma, Barcelona, Spain.,Woman and Perinatal Health Research Group, Sant Pau Biomedical Research Institute (IIB-Sant Pau), Sant Pau University Hospital, Barcelona, Spain
| | - Monica Cruz-Lemini
- Obstetrics and Gynecology Department, Santa Creu i Sant Pau University Hospital & Universitat Autònoma, Barcelona, Spain.,Woman and Perinatal Health Research Group, Sant Pau Biomedical Research Institute (IIB-Sant Pau), Sant Pau University Hospital, Barcelona, Spain.,Maternal and Child Health and Development Network (SAMID), RD16/0022/0015, Instituto de Salud Carlos III, Madrid, Spain
| | - Olga Sánchez-García
- Woman and Perinatal Health Research Group, Sant Pau Biomedical Research Institute (IIB-Sant Pau), Sant Pau University Hospital, Barcelona, Spain.,Maternal and Child Health and Development Network (SAMID), RD16/0022/0015, Instituto de Salud Carlos III, Madrid, Spain
| | - Lidia Bos-Real
- Woman and Perinatal Health Research Group, Sant Pau Biomedical Research Institute (IIB-Sant Pau), Sant Pau University Hospital, Barcelona, Spain.,Cardiology Department, Santa Creu i Sant Pau University Hospital, Barcelona, Spain
| | - Patricia Fernandez De La Llama
- Woman and Perinatal Health Research Group, Sant Pau Biomedical Research Institute (IIB-Sant Pau), Sant Pau University Hospital, Barcelona, Spain.,Nephrology Department, Hypertension and Prevention of Kidney Damage Unit, Fundació Puigvert, Barcelona, Spain
| | - Francesca Calero
- Woman and Perinatal Health Research Group, Sant Pau Biomedical Research Institute (IIB-Sant Pau), Sant Pau University Hospital, Barcelona, Spain.,Nephrology Department, Hypertension and Prevention of Kidney Damage Unit, Fundació Puigvert, Barcelona, Spain
| | - Carla Domínguez-Gallardo
- Obstetrics and Gynecology Department, Santa Creu i Sant Pau University Hospital & Universitat Autònoma, Barcelona, Spain.,Woman and Perinatal Health Research Group, Sant Pau Biomedical Research Institute (IIB-Sant Pau), Sant Pau University Hospital, Barcelona, Spain
| | - Carmen Garrido-Gimenez
- Obstetrics and Gynecology Department, Santa Creu i Sant Pau University Hospital & Universitat Autònoma, Barcelona, Spain.,Woman and Perinatal Health Research Group, Sant Pau Biomedical Research Institute (IIB-Sant Pau), Sant Pau University Hospital, Barcelona, Spain
| | - Cristina Trilla
- Obstetrics and Gynecology Department, Santa Creu i Sant Pau University Hospital & Universitat Autònoma, Barcelona, Spain.,Woman and Perinatal Health Research Group, Sant Pau Biomedical Research Institute (IIB-Sant Pau), Sant Pau University Hospital, Barcelona, Spain
| | | | - Alessandro Sionis
- Cardiology Department, Santa Creu i Sant Pau University Hospital, Barcelona, Spain
| | - Josefina Mora
- Woman and Perinatal Health Research Group, Sant Pau Biomedical Research Institute (IIB-Sant Pau), Sant Pau University Hospital, Barcelona, Spain.,Biochemistry Department, Santa Creu i Sant Pau University Hospital & Universitat Autònoma, Barcelona, Spain
| | - Álvaro García-Osuna
- Woman and Perinatal Health Research Group, Sant Pau Biomedical Research Institute (IIB-Sant Pau), Sant Pau University Hospital, Barcelona, Spain.,Fundació per la Bioquímica i la Patología Molecular, Biochemistry Department, Santa Creu i Sant Pau University Hospital & Universitat Autònoma, Barcelona, Spain
| | - Jordi Ordoñez-Llanos
- Biochemistry Department, Santa Creu i Sant Pau University Hospital & Universitat Autònoma, Barcelona, Spain.,Fundació per la Bioquímica i la Patología Molecular, Biochemistry Department, Santa Creu i Sant Pau University Hospital & Universitat Autònoma, Barcelona, Spain
| | - Elisa Llurba
- Obstetrics and Gynecology Department, Santa Creu i Sant Pau University Hospital & Universitat Autònoma, Barcelona, Spain. .,Woman and Perinatal Health Research Group, Sant Pau Biomedical Research Institute (IIB-Sant Pau), Sant Pau University Hospital, Barcelona, Spain. .,Maternal and Child Health and Development Network (SAMID), RD16/0022/0015, Instituto de Salud Carlos III, Madrid, Spain.
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11
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Sheikh M, Ostadrahimi P, Salarzaei M, Parooie F. Cardiac Complications in Pregnancy: A Systematic Review and Meta-Analysis of Diagnostic Accuracy of BNP and N-Terminal Pro-BNP. Cardiol Ther 2021; 10:501-514. [PMID: 34213737 PMCID: PMC8555044 DOI: 10.1007/s40119-021-00230-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 06/12/2021] [Indexed: 01/22/2023] Open
Abstract
Introduction Serum brain-type natriuretic peptide (BNP) levels may be involved in detecting the breakdown of defense mechanisms in pregnant women. BNP and N-terminal pro-BNP (NT-proBNP) levels can be used in emergency settings as a biomarker to rule out or confirm cardiac complications. The present study was conducted as an attempt to evaluate the performance of BNP and NT-proBNP as diagnostic tools for cardiac complications, including heart failure and pre-eclampsia, in pregnant and recently-delivered women. Methods This meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. To extract the data, articles meeting the inclusion criteria were directly reviewed by two of the authors. Disputes were resolved through discussion with all authors before data mining. In cases of unresolved disagreement, a third reviewer was consulted to achieve consensus. A quantitative analysis of the total bias of publications was performed using Stata software version 14.0, using funnel plots and Deek’s test. Results Overall, 13 unique studies were included in this review. The pooled sensitivity, specificity and positive and negative predictive values for diagnosing cardiac complications in pregnant women when BNP level was ≤ 100 ng/L, were determined to be 95, 62, 71 and 91%, respectively. The corresponding measures when the BNP levels were 100–500 ng/L were calculated to be 98, 92, 97 and 92%, respectively. The pooled sensitivity, specificity and positive and negative predictive values for diagnosing cardiac complications in pregnant women using NT-proBNP were 78, 74, 20.5 and 97%, respectively. Conclusion Our results suggest that both BNP and NT-proBNP levels can be used as diagnostic tools among pregnant and newly-delivered women to diagnose cardiac complications, including heart failure and pre-eclampsia. While BNP showed a relatively better diagnostic accuracy compared to NT-proBNP, it must be noted that the number of studies evaluating NT-proBNP included in this meta-analysis was low and the studies were inconsistent in terms of cutoff value. Further studies are required to confirm the prospective use of BNP and NT-pro BNP in assessing common symptoms that indicate cardiac complications during labor. Moreover, the clinical use of the NT-proBNP test in this field requires further study.
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Affiliation(s)
- Mahboobeh Sheikh
- Department of Cardiology, Faculty of Medicine, Zabol University of Medical Sciences, Zabol, Iran
| | - Pouya Ostadrahimi
- Faculty of Medicine, Zabol University of Medical Sciences, Zabol, Iran.
| | - Morteza Salarzaei
- Faculty of Medicine, Zabol University of Medical Sciences, Zabol, Iran
| | - Fateme Parooie
- Faculty of Medicine, Zabol University of Medical Sciences, Zabol, Iran
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12
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Lafuente-Ganuza P, Lequerica-Fernandez P, Carretero F, Escudero AI, Martinez-Morillo E, Sabria E, Herraiz I, Galindo A, Lopez A, Martinez-Triguero ML, Alvarez FV. A more accurate prediction to rule in and rule out pre-eclampsia using the sFlt-1/PlGF ratio and NT-proBNP as biomarkers. Clin Chem Lab Med 2021; 58:399-407. [PMID: 31734648 DOI: 10.1515/cclm-2019-0939] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 10/12/2019] [Indexed: 12/16/2022]
Abstract
Background The management of potential pre-eclamptic patients using the soluble FMS-like tyrosine kinase 1 (sFlt-1)/ placental growth factor (PlGF) ratio is characterised by frequent false-positive results. Methods A retrospective cohort study was conducted to identify and validate cut-off values, obtained using a machine learning model, for the sFlt-1/PlGF ratio and NT-proBNP that would be predictive of the absence or presence of early-onset pre-eclampsia (PE) in singleton pregnancies presenting at 24 to 33 + 6 weeks of gestation. Results For the development cohort, we defined two sFlt-1/PlGF ratio cut-off values of 23 and 45 to rule out and rule in early-onset PE at any time between 24 and 33 + 6 weeks of gestation. Using an sFlt-1/PlGF ratio cut-off value of 23, the negative predictive value (NPV) for the development of early-onset PE was 100% (95% confidence interval [CI]: 99.5-100). The positive predictive value (PPV) of an sFlt-1/PlGF ratio >45 for a diagnosis of early-onset PE was 49.5% (95% CI: 45.8-55.6). When an NT-proBNP value >174 was combined with an sFlt-1/PlGF ratio >45, the PPV was 86% (95% CI: 79.2-92.6). In the validation cohort, the negative and positive values were very similar to those found for the development cohort. Conclusions An sFlt-1/PlGF ratio <23 rules out early-onset PE between 24 and 33 + 6 weeks of gestation at any time, with an NPV of 100%. An sFlt-1/PlGF ratio >45 with an NT-proBNP value >174 significantly enhances the probability of developing early-onset PE.
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Affiliation(s)
- Paula Lafuente-Ganuza
- Clinical Biochemistry, Laboratory Medicine, Hospital Universitario Central de Asturias, Avenida de Roma, s/n, 33011 Oviedo, Spain
| | - Paloma Lequerica-Fernandez
- Clinical Biochemistry, Laboratory Medicine, Hospital Universitario Central de Asturias, Avenida de Roma, s/n, 33011 Oviedo, Spain
| | | | - Ana I Escudero
- Obstetrics and Gynaecology Department, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Eduardo Martinez-Morillo
- Clinical Biochemistry, Laboratory Medicine, Hospital Universitario Central de Asturias, Avenida de Roma, s/n, 33011 Oviedo, Spain
| | - Enric Sabria
- Obstetrics and Gynaecology Department, Hospital-Residencia Sant Camil, Barcelona, Spain
| | - Ignacio Herraiz
- Fetal Medicine Unit, Maternal and Child Health and Development Network, Department of Obstetrics and Gynaecology, University Hospital 12 de Octubre, Complutense University of Madrid, Madrid, Spain
| | - Alberto Galindo
- Fetal Medicine Unit, Maternal and Child Health and Development Network, Department of Obstetrics and Gynaecology, University Hospital 12 de Octubre, Complutense University of Madrid, Madrid, Spain
| | - Ana Lopez
- Clinical Laboratory, University Hospital 12 de Octubre, Madrid, Spain
| | | | - Francisco V Alvarez
- Clinical Biochemistry, Laboratory Medicine, Hospital Universitario Central de Asturias, Avenida de Roma, s/n, 33011 Oviedo, Spain
- Department of Biochemistry and Molecular Biology, Universidad de Oviedo, Oviedo, Spain
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13
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Eroğlu H, Tonyalı NV, Orgul G, Biriken D, Yucel A, Yazihan N, Uygur D. Is ProBNP a New Marker for Predicting Intrauterine Growth Restriction? Z Geburtshilfe Neonatol 2021; 225:125-128. [PMID: 33694150 DOI: 10.1055/a-1382-8787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PURPOSE To evaluate the usability of first-trimester maternal serum ProBNP levels in the prediction of intrauterine growth restriction (IUGR). Methods In this prospective study, blood samples taken from 500 women who applied to our polyclinic for routine serum aneuploidy screening between the 11-14th gestational weeks were centrifuged. The obtained plasma samples were placed in Eppendorf tubes and stored at -80+°C. For the final analysis, first-trimester maternal serum ProBNP levels of 32 women diagnosed with postpartum IUGR and 32 healthy women randomly selected as the control group were compared. FGR was defined as estimated fetal weight below the 10th percentile for the gestational age. RESULTS The mean ProBNP levels were statistically and significantly higher in the women with intrauterine growth restriction (113.73±94.69 vs. 58.33±47.70 pg/mL, p<0.01). At a cut-off level of 50.93, ProBNP accurately predicted occurrence of IUGR (AUC+= 0.794 (95% confidence interval 0.679-0.910), p+= 0.001) with sensitivity and specificity rates of 78.1 and 69.0%, respectively. Conclusion First-trimester serum ProBNP level was significantly higher in women who developed IUGR compared to healthy controls. First-trimester ProBNP level can be used as a potential marker to predict the development of IUGR in pregnant women.
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Affiliation(s)
- Hasan Eroğlu
- Department of Perinatology, Etlik Lady Zübeyde Gynaecology Education and Research Hospital, Ankara, Turkey
| | - Nazan Vanlı Tonyalı
- Department of Perinatology, Etlik Lady Zübeyde Gynaecology Education and Research Hospital, Ankara, Turkey
| | - Gokcen Orgul
- Department of Perinatology, Etlik Lady Zübeyde Gynaecology Education and Research Hospital, Ankara, Turkey
| | - Derya Biriken
- Microbiology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Aykan Yucel
- Department of Perinatology, Etlik Lady Zübeyde Gynaecology Education and Research Hospital, Ankara, Turkey
| | - Nuray Yazihan
- Ankara University, Faculty of Medicine, Pathophysiology Department
| | - Dilek Uygur
- Department of Perinatology, Etlik Lady Zübeyde Gynaecology Education and Research Hospital, Ankara, Turkey
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14
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Lafuente-Ganuza P, Carretero F, Lequerica-Fernández P, Fernandez-Bernardo A, Escudero AI, de la Hera-Galarza JM, Garcia-Iglesias D, Alvarez-Velasco R, Alvarez FV. NT-proBNP levels in preeclampsia, intrauterine growth restriction as well as in the prediction on an imminent delivery. Clin Chem Lab Med 2021; 59:1077-1085. [PMID: 33581001 DOI: 10.1515/cclm-2020-1450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 01/05/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Studies of cardiovascular function in pregnancy have shown inconsistent and, in some cases, contradictory results, particularly regarding cardiac output. While some studies report preeclampsia associated with high cardiac output, other studies suggest that preeclampsia should be further subdivided into women with high or low cardiac output. This study was conducted to examine the NT-proBNP levels in preeclampsia, intrauterine growth restriction, and hypertensive pregnancies without preeclampsia. We also examined N-terminal pro-B natriuretic peptide (NT-proBNP) levels three to four months after delivery, in preeclamptic women as well as the prediction of delivery within 10 days. In a reduced number of preeclamptic women and controls we performed echocardiograms to study their diastolic function. METHODS We investigated the NT-proBNP levels in 213 subjects with preeclampsia only, 73 with intrauterine growth restriction, 44 with preeclampsia and intrauterine growth restriction, 211 who were hypertensive and 662 unaffected pregnancies (controls). We also performed echocardiograms on 36 preeclampsia and 19 controls before delivery and three to five months after delivery. RESULTS NT-proBNP levels are higher in early onset preeclampsia than in late onset preeclampsia. Intrauterine growth restriction pregnancies showed a NT-proBNP levels similar to hypertensive and unaffected pregnancies. Compared with healthy pregnancies, women with preterm preeclampsia (<37 gestational weeks) had altered left atrial segments. CONCLUSIONS We observed that NT-proBNP levels are higher in early onset preeclampsia than in late onset. Moreover, diastolic dysfunction is higher in early onset than in late-onset term preeclampsia. An NT-proBNP value >136 pg/mL has a high positive predictive value for an imminent delivery within 10 days.
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Affiliation(s)
- Paula Lafuente-Ganuza
- Clinical Biochemistry, Laboratory Medicine, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
| | - Fran Carretero
- Clinical Biochemistry, Laboratory Medicine, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
| | - Paloma Lequerica-Fernández
- Clinical Biochemistry, Laboratory Medicine, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
| | - Ana Fernandez-Bernardo
- Obstetrics and Gynecology Department, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
| | - Ana I Escudero
- Obstetrics and Gynecology Department, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
| | - Jesus M de la Hera-Galarza
- Cardiology Department, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain.,Instituto de Investigacion Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
| | | | - Rut Alvarez-Velasco
- Cardiology Department, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
| | - Francisco V Alvarez
- Clinical Biochemistry, Laboratory Medicine, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain.,Department of Biochemistry and Molecular Biology, Universidad de Oviedo, Oviedo, Spain
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15
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Gondek A, Jagodzińska A, Pietrzak B, Mamcarz A, Cudnoch-Jędrzejewska A. Relevance of the assessment of natriuretic peptide plasma concentrations in hypertensive pregnant women. Biomarkers 2020; 25:449-457. [PMID: 32693619 DOI: 10.1080/1354750x.2020.1795264] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Assessment of the plasma concentrations of natriuretic peptides (NPs) is widely used to diagnose and evaluate the progression of cardiac failure, and their potential as markers of preeclampsia (PE) has been examined in recent years. It has been established that plasma concentrations of NPs do not change in the course of normal pregnancy. However, elevated levels of these peptides may have a prognostic value in patients with PE. This study presents information about the relevance of NPs assessment in the evaluation of physiological pregnancy, as well as in pregnancy complicated with arterial hypertension. The most commonly examined NPs is the N-terminal fragment of the brain natriuretic peptide (NT-proBNP), and it may be prognostic marker of PE and other complications of pregnancy.
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Affiliation(s)
- Agata Gondek
- Department of Methodology, Laboratory of Centre for Preclinical Research, Medical University of Warsaw, Warsaw, Poland
| | - Aleksandra Jagodzińska
- Chair and Department of Experimental and Clinical Physiology, Laboratory of Centre for Preclinical Research, Medical University of Warsaw, Warsaw, Poland.,1st Department of Obstetrics and Gynecology, Medical University of Warsaw, Warsaw, Poland
| | - Bronisława Pietrzak
- 1st Department of Obstetrics and Gynecology, Medical University of Warsaw, Warsaw, Poland
| | - Artur Mamcarz
- 3rd Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Agnieszka Cudnoch-Jędrzejewska
- Chair and Department of Experimental and Clinical Physiology, Laboratory of Centre for Preclinical Research, Medical University of Warsaw, Warsaw, Poland
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16
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Brooks VL, Fu Q, Shi Z, Heesch CM. Adaptations in autonomic nervous system regulation in normal and hypertensive pregnancy. HANDBOOK OF CLINICAL NEUROLOGY 2020; 171:57-84. [PMID: 32736759 DOI: 10.1016/b978-0-444-64239-4.00003-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
There is an increase in basal sympathetic nerve activity (SNA) during normal pregnancy; this counteracts profound primary vasodilation. However, pregnancy also impairs baroreflex control of heart rate and SNA, contributing to increased mortality secondary to peripartum hemorrhage. Pregnancy-induced hypertensive disorders evoke even greater elevations in SNA, which likely contribute to the hypertension. Information concerning mechanisms is limited. In normal pregnancy, increased angiotensin II acts centrally to support elevated SNA. Hypothalamic sites, including the subfornical organ, paraventricular nucleus, and arcuate nucleus, are likely (but unproven) targets. Moreover, no definitive mechanisms for exaggerated sympathoexcitation in hypertensive pregnancy have been identified. In addition, normal pregnancy increases gamma aminobutyric acid inhibition of the rostral ventrolateral medulla (RVLM), a key brainstem site that transmits excitatory inputs to spinal sympathetic preganglionic neurons. Accumulated evidence supports a major role for locally increased production and actions of the neurosteroid allopregnanolone as one mechanism. A consequence is suppression of baroreflex function, but increased basal SNA indicates that excitatory influences predominate in the RVLM. However, many questions remain regarding other sites and factors that support increased SNA during normal pregnancy and, more importantly, the mechanisms underlying excessive sympathoexcitation in life-threatening hypertensive pregnancy disorders such as preeclampsia.
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Affiliation(s)
- Virginia L Brooks
- Department of Physiology and Pharmacology, Oregon Health & Science University, Portland, OR, United States.
| | - Qi Fu
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, TX, United States; Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Zhigang Shi
- Department of Physiology and Pharmacology, Oregon Health & Science University, Portland, OR, United States
| | - Cheryl M Heesch
- Department of Biomedical Sciences and Dalton Cardiovascular Research Center, University of Missouri, Columbia, MO, United States
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17
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Affiliation(s)
- Basky Thilaganathan
- From the Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, United Kingdom (B.T.).,Molecular and Clinical Sciences Research Institute, St George's University of London, United Kingdom (B.T.)
| | - Erkan Kalafat
- Faculty of Medicine, Department of Obstetrics and Gynecology, Ankara University, Turkey (E.K.)
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18
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Pihl K, Sørensen S, Stener Jørgensen F. Prediction of Preeclampsia in Nulliparous Women according to First Trimester Maternal Factors and Serum Markers. Fetal Diagn Ther 2019; 47:277-283. [PMID: 31622970 DOI: 10.1159/000503229] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 09/06/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To evaluate the performance of maternal risk factors (BMI and mean arterial pressure [MAP]) and first-trimester maternal serum markers in the early prediction of preeclampsia (PE) in nulliparous women. MATERIAL AND METHODS This was a case-cohort study based on a cohort of 14,207 nulliparous women. A total of 213 cases with term PE (from 37 weeks + 0 days) and 55 cases with preterm PE (before 37 weeks + 0 days) were identified and validated. Randomly, 449 controls were selected. Serum samples previously collected for the double test (pregnancy-associated plasma protein A [PAPP-A] and free β human chorionic gonadotrophin [hCGβ]) as part of the first-trimester screening program were retrieved and analyzed for placental growth factor (PlGF), soluble fms-like tyrosine kinase 1 (sFlt-1), N-terminal pro-B-type natriuretic peptide (NT-proBNP), and neutrophil gelatinase-associated lipocalin (NGAL). Concentrations were transformed to multiples of the median (MoM). Multivariate regression analysis was used for prediction models. Receiver-operating characteristics (ROC) curves were used for evaluation of the screening performance. RESULTS In preterm PE, the PlGF (0.79 MoM), sFlt-1 (0.86 MoM), NGAL (1.15 MoM), and PAPP-A (0.89 MoM) medians were significantly altered. In term PE, PlGF (0.90 MoM) and NT-proBNP (0.86 MoM) medians were significantly reduced. The combination of MAP and PlGF yielded a 39% detection rate of preterm PE for a 10% false-positive rate. The combination of MAP, BMI, and PlGF yielded a 33% detection rate of term PE with a 10% false-positive rate. CONCLUSION First-trimester MAP, maternal serum PlGF, and NGAL are markers of preterm PE. Maternal serum sFlt-1 is a significant marker of preterm PE, but only early in the first trimester. First-trimester maternal serum NT-proBNP is not a predictor of PE. Screening performance for PE with these markers individually or in combination is modest.
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Affiliation(s)
- Kasper Pihl
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark,
| | - Steen Sørensen
- Department of Clinical Biochemistry, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Finn Stener Jørgensen
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
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Sensitivity and Specificity of B-Type Natriuretic Peptide in Diagnosing Heart Failure in Pregnancy. Obstet Gynecol 2019; 134:440-449. [DOI: 10.1097/aog.0000000000003419] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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20
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Bijl RC, Valensise H, Novelli GP, Vasapollo B, Wilkinson I, Thilaganathan B, Stöhr EJ, Lees C, van der Marel CD, Cornette JMJ. Methods and considerations concerning cardiac output measurement in pregnant women: recommendations of the International Working Group on Maternal Hemodynamics. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 54:35-50. [PMID: 30737852 DOI: 10.1002/uog.20231] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 01/18/2019] [Accepted: 01/24/2019] [Indexed: 06/09/2023]
Abstract
Cardiac output (CO), along with blood pressure and vascular resistance, is one of the most important parameters of maternal hemodynamic function. Substantial changes in CO occur in normal pregnancy and in most obstetric complications. With the development of several non-invasive techniques for the measurement of CO, there is a growing interest in the determination of this parameter in pregnancy. These techniques were initially developed for use in critical-care settings and were subsequently adopted in obstetrics, often without appropriate validation for use in pregnancy. In this article, methods and devices for the measurement of CO are described and compared, and recommendations are formulated for their use in pregnancy, with the aim of standardizing the assessment of CO and peripheral vascular resistance in clinical practice and research studies on maternal hemodynamics. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- R C Bijl
- Department of Obstetrics and Gynecology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - H Valensise
- Department of Obstetrics and Gynecology, Tor Vergata University, Rome, Italy
- Division of Obstetrics and Gynecology, Policlinico Casilino Hospital, Rome, Italy
| | - G P Novelli
- Department of Cardiology, San Sebastiano Martire Hospital, Frascati, Italy
| | - B Vasapollo
- Division of Obstetrics and Gynecology, Policlinico Casilino Hospital, Rome, Italy
| | - I Wilkinson
- Division of Experimental Medicine and Immunotherapeutics, University of Cambridge, Cambridge, UK
| | - B Thilaganathan
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - E J Stöhr
- Cardiff School of Sport & Health Sciences, Cardiff Metropolitan University, Cardiff, UK
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, USA
| | - C Lees
- Department of Obstetrics, Imperial College, London, UK
| | - C D van der Marel
- Department of Anesthesiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - J M J Cornette
- Department of Obstetrics and Gynecology, Erasmus Medical Center, Rotterdam, The Netherlands
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21
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Mulder E, Basit S, Oben J, van Kuijk S, Ghossein-Doha C, Spaanderman M. Accuracy and precision of USCOM versus transthoracic echocardiography before and during pregnancy. Pregnancy Hypertens 2019; 17:138-143. [PMID: 31487631 DOI: 10.1016/j.preghy.2019.04.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 04/08/2019] [Accepted: 04/15/2019] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Monitoring hemodynamic status throughout pregnancy may help in identifying women with maladaptation predisposing to hypertensive complications. The Ultrasonic Cardiac Output Monitor (USCOM) is an easy-to-operate device for measuring cardiac output (CO) quickly. Our aim was to assess agreement between USCOM and transthoracic echocardiography (TTE) in: 1) non-pregnant women to correct for possible sources of discrepancy; 2) women longitudinally over the course of the pregnancy. STUDY DESIGN High-risk women admitted for cardiovascular risk factor evaluation before pregnancy and multiple times during pregnancy, were included. CO was measured by TTE directly followed by USCOM measurements. MAIN OUTCOME MEASURES Bias, limits of agreement (LOA) and percentage error between the two methods by Bland-Altman analysis. RESULTS Despite comparable non-pregnant CO levels (4.6 L/min), LOA and percentage error between the two methods improved moderately by optimizing the measurements using only the highest quality USCOM recordings in 132 non-pregnant women (percentage error of 39% and 30%, respectively). During pregnancy, in total 83, 106, 96 and 77 measurements were evaluated at respectively 12, 16, 20 and 30 weeks gestational age. Mean CO in USCOM was about 0.6 L/min higher compared to TTE in all trimesters; percentage error ranged from 35% to 45%. Linear mixed model analysis showed no association between bias and moment of measurement. CONCLUSION Agreement between USCOM and TTE in pregnancy was outside our a priori determined level of acceptability and therefore absolute values of USCOM and TTE cannot be used interchangeably. Future research should focus on the agreement of USCOM and TTE in clinical decision-making.
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Affiliation(s)
- Eva Mulder
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, PO Box 5800, 6202 AZ Maastricht, the Netherlands.
| | - Shumalla Basit
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, PO Box 5800, 6202 AZ Maastricht, the Netherlands
| | - Jolien Oben
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, PO Box 5800, 6202 AZ Maastricht, the Netherlands.
| | - Sander van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, PO Box 5800, 6202 AZ Maastricht, the Netherlands.
| | - Chahinda Ghossein-Doha
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, PO Box 5800, 6202 AZ Maastricht, the Netherlands; Department of Cardiology, Maastricht University Medical Centre, PO Box 5800, 6202 AZ Maastricht, the Netherlands.
| | - Marc Spaanderman
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, PO Box 5800, 6202 AZ Maastricht, the Netherlands.
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Mingels AMA, Kimenai DM. Sex-Related Aspects of Biomarkers in Cardiac Disease. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1065:545-564. [PMID: 30051406 DOI: 10.1007/978-3-319-77932-4_33] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Biomarkers play an important role in the clinical management of cardiac care. In particular, cardiac troponins (cTn) and natriuretic peptides are the cornerstones for the diagnosis of acute myocardial infarction (AMI) and for the diagnosis of heart failure (HF), respectively. Current guidelines do not make a distinction between women and men. However, the commonly used "one size fits all" algorithms are topic of debate to improve assessment of prognosis, particularly in women. Due to the high-sensitivity assays (hs-cTn), lower cTn levels (and 99th percentile upper reference limits) were observed in women as compared with men. Sex-specific diagnostic thresholds may improve the diagnosis of AMI in women, though clinical relevance remains controversial and more trials are needed. Also other diagnostic aspects are under investigation, like combined biomarkers approach and rapid measurement strategies. For the natriuretic peptides, previous studies observed higher concentrations in women than in men, especially in premenopausal women who might benefit from the cardioprotective actions. Contrary to hs-cTn, natriuretic peptides are particularly incorporated in the ruling-out algorithms for the diagnosis of HF and not ruling-in. Clinical relevance of sex differences here seems marginal, as clinical research has shown that negative predictive values for ruling-out HF were hardly effected when applying a universal diagnostic threshold that is independent from sex or other risk factors. Apart from the diagnostic issues of AMI in women, we believe that in the future most sex-specific benefits of cardiac biomarkers can be obtained in patient follow-up (guiding therapy) and prognostic applications, fitting modern ideas on preventive and personalized medicine.
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Affiliation(s)
- Alma M A Mingels
- Department of Clinical Chemistry, Central Diagnostic Laboratory, Maastricht University Medical Center, Maastricht, The Netherlands.
| | - Dorien M Kimenai
- Department of Clinical Chemistry, Central Diagnostic Laboratory, Maastricht University Medical Center, Maastricht, The Netherlands
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