Novel risk scores predict adverse CV events for pregnant women with valvular heart disease
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Key takeaways:
- Two risk calculators were useful for predicting cardiac events in pregnant patients with valvular heart disease.
- More studies are needed with an extended postpartum period.
Researchers reported that two novel risk classification scores correctly classified patients with valvular heart disease living in India who developed adverse CV outcomes during pregnancy and childbirth.
“Acquired (rheumatic) valvular heart disease is responsible for a disproportionately higher proportion of pregnancy-related deaths and severe illness than congenital heart disease in low- and middle-income countries,” Anish Keepanasseril, MD, of the department of obstetrics and gynecology in the Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER) in Puducherry, India, and colleagues wrote in the study background. “Risk stratification of pregnancies with valvular heart disease is crucial, especially in low-to-middle-income countries, to facilitate early referral to multidisciplinary cardio-obstetrics teams in tertiary referral centers and to improve pregnancy outcomes.”
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The researchers noted that most risk stratification score models are developed in high-income settings, where congenital heart disease is more prevalent. Valvular heart disease, especially rheumatic disease, typically comprises only a small proportion of these development and validation cohorts. The researchers sought to evaluate a risk score developed and internally validated in patients with valvular heart disease living in a middle-income country, the DEVI score, and evaluate its performance through temporal validation in a cohort of cases from the same setting.
Assessing outcomes in rheumatic disease
In a prospective study, Keepanasseril and colleagues analyzed data from 577 women who developed valvular heart disease before or during pregnancy, admitted to a tertiary center in the southeastern coastal region of India from January 2019 to April 2022. Researchers calculated individual risk for adverse composite CV events using the DEVI and CARPREG-II models, assessing performance via discrimination and calibration characteristics.
The primary outcome was a composite of adverse CV events, defined as CV death, cardiac arrest, HF, valvular or extravalvular thrombotic events or cerebrovascular accidents, such as stroke or transient ischemic attack, and new-onset or recurrent arrhythmias requiring treatment.
The findings were published in the Journal of the American College of Cardiology.
Within the cohort, 12.1% of pregnant patients experienced a component of the composite outcome. Most (94.7%) had rheumatic etiology, with mitral regurgitation as the predominant lesion (48.2%).
The area under the receiver-operating characteristic curve was 0.884 (95% CI, 0.844-0.923) for the DEVI model and 0.808 (95% CI, 0.753-0.863) for the CARPREG-II model.
The researchers wrote that calibration plots suggested that DEVI score overestimates risk at higher probabilities, whereas CARPREG-II score overestimates risk at both extremes and underestimates risk at middle probabilities.
Decision curve analysis demonstrated that both models were useful across predicted probability thresholds between 10% and 50%.
“The lesion-specific DEVI score showed better agreement between the predicted and observed events (calibration),” the researchers wrote. “However, the DEVI score needs to be externally validated in diverse community settings to increase its usability and clinical application.”
The researchers noted that the study period was restricted to 3 to 5 days postpartum, which is reflective of when patients are routinely discharged from the hospital. “Acknowledging that many adverse events occur later in the postpartum period, future studies need to consider follow-up in the extended postpartum period,” the researchers wrote.
Preventing missed diagnoses
In a related editorial published in JACC, Healio | Cardiology Today Editorial Board Member Garima Sharma, MD, FAHA, director of women’s cardiovascular health and cardio-obstetrics at Inova Health System in Falls Church, Virginia, and adjunct associate professor of medicine at Johns Hopkins Medicine, and colleagues wrote that an intrapartum risk score to prevent missed diagnoses would be useful to provide earlier referral to appropriate care.
“Enhancement of these cardiovascular risk scores in pregnancy for specific populations is a natural extension of their clinical utility, and Pande et al should be congratulated on their efforts to do so,” Sharma and colleagues wrote. “The validation and broad adoption of valve-specific risk scores, which align more adeptly with the prevailing cardiac condition predominant in a given population — such as the instance of rheumatic heart disease highlighted here — herald an idea that has now reached its prime moment.”
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