haemodynamics using transthoracic echocardiography in ... · rationale for the study preeclampsia...
TRANSCRIPT
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AT Dennis, RA Dyer, M Gibbs, L Nel, J Castro, J Swanevelder
Royal Women’s Hospital, St Vincent’s Hospital Melbourne, & University of Melbourne, Australia, Groote Schuur Hospital & University of Cape Town, South Africa
Obstetric Anaesthetists Meeting Dublin Ireland May 2014
Haemodynamics using transthoracic echocardiography in women with untreated severe preeclampsia in
South Africa
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Disclosures
none
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Overview
1. Rationale for the study
2. Aims
3. Method
4. Results
5. Conclusions
6. Acknowledgements
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Rationale for the study
Preeclampsia is a life-threatening hypertensive disease of pregnancy
6.5 million women affected each year
Major cause of stroke, heart failure, kidney impairment, haemorrhage and premature birth
Lowe, S. A., M. A. Brown, G. A. Dekker, S. Gatt, C. K. McLintock, L. P. McMahon, G. Mangos, M. P. Moore, P. Muller, M. Paech and B. Walters (2009). "Guidelines for the management of hypertensive disorders of pregnancy 2008." Australian and New Zealand Journal of Obstetrics and Gynaecology 49(3): 242-246.Goldkind, S. F., L. Sahin and B. Gallauresi (2010). "Enrolling pregnant women in research--lessons from the H1N1 influenza pandemic." N Engl J Med 362(24): 2241-2243.
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Rationale for the study
Pathophysiology – there is a need to conduct scientific observations on women with untreated disease in order to understand heart function and the underlying mechanisms for the cardiac changes
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Rationale for the study
Australia (2008-2013)
Maternal Mortality Ratio
6/100,000 live births
• Healthy pregnant women
• Women with untreated preeclampsia (mild and severe)
• Women with treated preeclampsia
Preeclampsia – preserved systolic function, reduced diastolic function, non-dilated ventricleLower cardiac outputs compared with treated women
Dennis, A. T. and J. M. Castro (2014). "Transthoracic echocardiography in women with treated severe pre-eclampsia." Anaesthesia 69(5): 436-444.Dennis, A. T., J. Castro, S. W. Simmons, M. Permezel and C. F. Royse (2012). "Haemodynamics in women with untreated pre-eclampsia." Anaesthesia 67(10): 1105-1118.Melchiorre, K., G. R. Sutherland, A. Baltabaeva, M. Liberati and B. Thilaganathan (2011). "Maternal cardiac dysfunction and remodeling in women with preeclampsia at term." Hypertension 57(1): 85-93.
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Rationale for the study
Australia (2008-2013)
Maternal Mortality Ratio
6/100,000 live births
• Healthy pregnant women
• Women with untreated preeclampsia (mild and severe)
• Women with treated preeclampsia
Preeclampsia – preserved systolic function, reduced diastolic function, non-dilated ventricleLower cardiac outputs compared with treated women
Dennis, A. T. and J. M. Castro (2014). "Transthoracic echocardiography in women with treated severe pre-eclampsia." Anaesthesia 69(5): 436-444.Dennis, A. T., J. Castro, S. W. Simmons, M. Permezel and C. F. Royse (2012). "Haemodynamics in women with untreated pre-eclampsia." Anaesthesia 67(10): 1105-1118.Melchiorre, K., G. R. Sutherland, A. Baltabaeva, M. Liberati and B. Thilaganathan (2011). "Maternal cardiac dysfunction and remodeling in women with preeclampsia at term." Hypertension 57(1): 85-93.
The Netherlands (1991)Visser and Wallenburg
Pulmonary artery catheter
87 women untreated preterm severe preeclampsia
Preeclampsia – reduced cardiac output in women with untreated preeclampsia compared with treated women, increased left ventricular stroke work index
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Rationale for the study
South Africa
Maternal Mortality Ratio
140/100,000 live births
Do women with preeclampsia in high MMR countries represent a different
phenotype and disease severity?
Visser, W. and H. C. Wallenburg (1991). "Central hemodynamic observations in untreated preeclamptic patients." Hypertension 17(6 Pt 2): 1072-1077.
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Aim
To determine heart function in women with severe untreated preeclampsia in a high MMR setting
http://www.who.int/research/en/
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Method
Institutional ethics approval & written consentTransthoracic echocardiography in pregnant women ACTRN12613000992707, HREC 442/2013 University of Cape Town and The Groote Schuur Hospital and The University of Melbourne and The Royal Women’s Hospital – AT Dennis, RA Dyer, M Gibbs, L Nel, J Castro, J Swanevelder
Prospective observational study performed during a 4 month period from August – December 2013 (investigator availability)
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Included women with preeclampsia
35
Women with untreated
preeclampsia15
All women recruited with preeclampsia
43
Term pregnant HIV infection
30
Term healthy pregnant
40
Term pregnant women with HIV
infection36
Term healthy pregnant women
47
Total number of women recruited
126
6 excluded 7 excluded
8 excluded
20 treated
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Included women with preeclampsia
35
Women with untreated
preeclampsia15
All women recruited with preeclampsia
43
Term pregnant HIV infection
30
Term healthy pregnant
40
Term pregnant women with HIV
infection36
Term healthy pregnant women
47
Total number of women recruited
126
6 excluded 7 excluded
8 excluded
20 treated
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Method
South Africa subgroup - 15 HIV negative women with single fetus, not in labour, no signs of pulmonary oedema, no pre-existing hypertensive, cardiac or renal disease, untreated severe preeclampsia:severe disease defined as systolic blood pressure ≥ 160 mmHg and/or diastolic blood pressure ≥ 100 mmHg, central nervous system symptoms, proteinuria, premature birth
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Method
Compared with
Australian subgroup
– 19 women with single fetus, not in labour, no signs of pulmonary oedema, no pre-existing hypertensive cardiac or renal disease, untreated severe preeclampsia (published data)
- 40 healthy pregnant women (published data)
Dennis, A. T. and J. M. Castro (2014). "Transthoracic echocardiography in women with treated severe pre-eclampsia." Anaesthesia 69(5): 436-444.Dennis, A. T., J. Castro, S. W. Simmons, M. Permezel and C. F. Royse (2012). "Haemodynamics in women with untreated pre-eclampsia." Anaesthesia 67(10): 1105-1118
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Method
Rested
Left lateral position
3-lead electrocardiograph
Blood pressure measured (mmHg)
Standardised echocardiography examination (ASE) image acquisition two investigators (A Dennis, L Nel)
Offline measurements
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Method
Variables were compared using t-tests with Welsh’s correction or Fisher’s exact test for proportions, inter-observer measurements were compared using Bland Altman methodology.
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Results
Haemodynamics were able to be assessed in all women (100%)
Interobserver measurements:95% of measurements are within 0.20 cm (10 %) of mean left ventricular outflow tract diameter
95% of measurements are within 2.3 cm/sec (11%) of mean velocity time integral
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Results
Characteristic AustraliaUntreated
severe preeclampsian = 19
South AfricaUntreated
severe preeclampsian = 15
P value
Age (years) 30 ± 6.1 26 ± 7.7 0.147
Body mass index (kg/m2) 32 ± 7.4 33 ± 8.0 0.582
Nulliparous 26 (65) 7 (47) 0.235
Gestation (weeks) 35 ± 4.9 36 ± 5.6 0.535
Haemoglobin (g/l) 125 ± 12.7Range (108 – 148)
103 ± 1.9*Range (68 -136)
<0.001
*60% of women were anaemic
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Results
Characteristic AustraliaUntreated
severe preeclampsian = 19
South AfricaUntreated
severe preeclampsian = 15
P value
Age (years) 30 ± 6.1 26 ± 7.7 0.147
Body mass index (kg/m2) 32 ± 7.4 33 ± 8.0 0.582
Nulliparous 26 (65) 7 (47) 0.235
Gestation (weeks) 35 ± 4.9 36 ± 5.6 0.535
Haemoglobin (g/l) 125 ± 12.7Range (108 – 148)
103 ± 1.9*Range (68 -136)
<0.001
*60% of women were anaemic
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ResultsCharacteristic Australia
Untreated severe preeclampsia
n = 19
South AfricaUntreated
severe preeclampsian = 15
P value
Mean arterial pressure (mmHg) 113 ± 5.0 120 ± 11.9 0.058
Cardiac output (ml/min) 4847 ± 1413 6581 ± 2066 0.011*
Cardiac index (cardiac output/m2) 2.5 ± 0.65 3.6 ± 0.94 0.002
Systemic vascular resistance (dyne.sec/cm5) 2060 ± 741.5 1593 ± 530.9 0.041
Left ventricular stroke work index (J/beat/m2) 0.48 ± 0.08 0.68 ± 0.10 <0.001*
Stroke volume (ml) 60 ± 13.9 79 ± 15.9 0.001*
Heart rate (beats per minute) 81 ± 14.1 83 ± 14.2 0.674
Left ventricular end diastolic diameter (cm) 4.5 ± 0.62 4.5 ± 0.49 0.923
Left ventricular mass (g) 192 ± 42.7 216 ± 32.2 0.066
Fractional shortening (%) 40.1 ± 9.2 40.1 ± 7.1 0.980
Mitral valve E/e’ 11.0 ± 2.2 10.5 ± 3.3 0.592
Tricuspid annular plane excursion (TAPSE) - 2.6 ± 0.4 -
Global left ventricular strain -18.1 ± 3.7
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ResultsCharacteristic Australia
Untreated severe preeclampsia
n = 19
South AfricaUntreated
severe preeclampsian = 15
P value
Mean arterial pressure (mmHg) 113 ± 5.0 120 ± 11.9 0.058
Cardiac output (ml/min) 4847 ± 1413 6581 ± 2066 0.011*
Cardiac index (cardiac output/m2) 2.5 ± 0.65 3.6 ± 0.94 0.002
Systemic vascular resistance (dyne.sec/cm5) 2060 ± 741.5 1593 ± 530.9 0.041
Left ventricular stroke work index (J/beat/m2) 0.48 ± 0.08 0.68 ± 0.10 <0.001*
Stroke volume (ml) 60 ± 13.9 79 ± 15.9 0.001*
Heart rate (beats per minute) 81 ± 14.1 83 ± 14.2 0.674
Left ventricular end diastolic diameter (cm) 4.5 ± 0.62 4.5 ± 0.49 0.923
Left ventricular mass (g) 192 ± 42.7 216 ± 32.2 0.066
Fractional shortening (%) 40.1 ± 9.2 40.1 ± 7.1 0.980
Mitral valve E/e’ 11.0 ± 2.2 10.5 ± 3.3 0.592
Tricuspid annular plane excursion (TAPSE) - 2.6 ± 0.4 -
Global left ventricular strain -18.1 ± 3.7
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ResultsCharacteristic Australia
Untreated severe preeclampsia
n = 19
South AfricaUntreated
severe preeclampsian = 15
P value
Mean arterial pressure (mmHg) 113 ± 5.0 120 ± 11.9 0.058
Cardiac output (ml/min) 4847 ± 1413 6581 ± 2066 0.011*
Cardiac index (cardiac output/m2) 2.5 ± 0.65 3.6 ± 0.94 0.002
Systemic vascular resistance (dyne.sec/cm5) 2060 ± 741.5 1593 ± 530.9 0.041
Left ventricular stroke work index (J/beat/m2) 0.48 ± 0.08 0.68 ± 0.10 <0.001*
Stroke volume (ml) 60 ± 13.9 79 ± 15.9 0.001*
Heart rate (beats per minute) 81 ± 14.1 83 ± 14.2 0.674
Left ventricular end diastolic diameter (cm) 4.5 ± 0.62 4.5 ± 0.49 0.923
Left ventricular mass (g) 192 ± 42.7 216 ± 32.2 0.066
Fractional shortening (%) 40.1 ± 9.2 40.1 ± 7.1 0.980
Mitral valve E/e’ 11.0 ± 2.2 10.5 ± 3.3 0.592
Tricuspid annular plane excursion (TAPSE) - 2.6 ± 0.4 -
Global left ventricular strain -18.1 ± 3.7
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ResultsCharacteristic Australia
Untreated severe preeclampsia
n = 19
South AfricaUntreated
severe preeclampsian = 15
P value
Mean arterial pressure (mmHg) 113 ± 5.0 120 ± 11.9 0.058
Cardiac output (ml/min) 4847 ± 1413 6581 ± 2066 0.011*
Cardiac index (cardiac output/m2) 2.5 ± 0.65 3.6 ± 0.94 0.002
Systemic vascular resistance (dyne.sec/cm5) 2060 ± 741.5 1593 ± 530.9 0.041
Left ventricular stroke work index (J/beat/m2) 0.48 ± 0.08 0.68 ± 0.10 <0.001*
Stroke volume (ml) 60 ± 13.9 79 ± 15.9 0.001*
Heart rate (beats per minute) 81 ± 14.1 83 ± 14.2 0.674
Left ventricular end diastolic diameter (cm) 4.5 ± 0.62 4.5 ± 0.49 0.923
Left ventricular mass (g) 192 ± 42.7 216 ± 32.2 0.066
Fractional shortening (%) 40.1 ± 9.2 40.1 ± 7.1 0.980
Mitral valve E/e’ 11.0 ± 2.2 10.5 ± 3.3 0.592
Tricuspid annular plane excursion (TAPSE) - 2.6 ± 0.4 -
Global left ventricular strain -18.1 ± 3.7
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Cardiac output
Healthy pregnant Preeclampsia Preeclampsia
0
5000
10000
15000
Australian=40
Untreated severeAustralia
n=19
Untreated severeSouth Africa
n=15
p = 0.011p = 0.040
*
**
Card
iac o
utp
ut
(ml/
min
)
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Cardiac output
Healthy pregnant Preeclampsia Preeclampsia
0
5000
10000
15000
Australian=40
Untreated severeAustralia
n=19
Untreated severeSouth Africa
n=15
p = 0.011p = 0.040
*
**
Card
iac o
utp
ut
(ml/
min
)
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Cardiac output
Healthy pregnant Preeclampsia Preeclampsia
0
5000
10000
15000
Australian=40
Untreated severeAustralia
n=19
Untreated severeSouth Africa
n=15
p = 0.011p = 0.040
*
**
Card
iac o
utp
ut
(ml/
min
)
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Cardiac output
Healthy pregnant Preeclampsia Preeclampsia
0
5000
10000
15000
Australian=40
Untreated severeAustralia
n=19
Untreated severeSouth Africa
n=15
p = 0.011p = 0.040
*
**
Card
iac o
utp
ut
(ml/
min
)
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Ejection fraction
Healthy Pregnant Preeclampsia Preeclampsia
0
20
40
60
28
Australian=40
Untreated severeAustralia
n=19
Untreated severeSouth Africa
n=15
p = 0.980p = 0.039
**
Fra
cti
on
al
sh
ort
en
ing
(%
)
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Ejection fraction
Healthy Pregnant Preeclampsia Preeclampsia
0
20
40
60
28
Australian=40
Untreated severeAustralia
n=19
Untreated severeSouth Africa
n=15
p = 0.980p = 0.039
**
Fra
cti
on
al
sh
ort
en
ing
(%
)
Reduced ejection fraction
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Contractility
Healthy Pregnant Preeclampsia Preeclampsia0.0
0.2
0.4
0.6
0.8
1.0
***
p < 0.001 p < 0.001
Australian=40
Untreated severeAustralia
n=19
Untreated severeSouth Africa
n=15
Left
ven
tric
ula
r str
oke w
ork
in
dex (
J/b
eat/
m2)
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Diastolic function
Healthy Pregnant Preeclampsia Preeclampsia
0
5
10
20
8
15
Untreated severeAustralia
n=19
Untreated severeSouth Africa
n=15
Australian=40
p = 0.592p < 0.0001
**
Mit
ral
valv
e E
velo
cit
y/s
ep
tal
e' velo
cit
y r
ati
o
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Diastolic function
Healthy Pregnant Preeclampsia Preeclampsia
0
5
10
20
8
15
Untreated severeAustralia
n=19
Untreated severeSouth Africa
n=15
Australian=40
p = 0.592p < 0.0001
**
Mit
ral
valv
e E
velo
cit
y/s
ep
tal
e' velo
cit
y r
ati
o
Reduced diastolic function
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Ventricular dilatation
Healthy Pregnant Preeclampsia Preeclampsia
0
2
4
6
5.3
Australian=40
Untreated severeSouth Africa
n=15
Untreated severeAustralia
n=19
p = 0.923p = 0.630
3.5
Left
ven
tric
ula
r en
d-d
iasto
lic d
iam
ete
r (c
m)
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Results
Untreated severe preeclampsia:
Increased cardiac output (↑ in South African group)
Increased contractility (↑ in South African group)
Increased ejection fraction
Preserved right ventricular systolic function
Reduced diastolic function
No ventricular dilatation
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Limitations
1. small study
2. small geographical area
3. comparisons with healthy are with Australian women
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Conclusions
1. Our observations suggest that severe preeclampsia is a hyperdynamic disease with
Increased cardiac output,
Increased contractility,
Preserved ejection fraction
Reduced diastolic function ( Australia and South Africa)
2. Higher cardiac output and left ventricular stroke work index in South African women ? anaemia - influence on haemodynamics/resting cardiac output/stress responses
3. In compensated disease (i.e. not in pulmonary oedema) our observations do not support the hypothesis that preeclampsia is associated with a reduction in systolic function or a dilated left ventricle
http://www.who.int/vmnis/anaemia/prevalence/summary/anaemia_status_summary/en
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Conclusions
4. Transthoracic echocardiography can be used at the bedside to quantity heart function in individual women
5. Further human research at the bedside to examine heart function in untreated women with preeclampsia is needed
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Acknowledgements
South AfricaRob Dyer, Justiaan Swanevelder, Matthew Gibbs, Lynel NelStaff at Mowbray Maternity and Groote Schuur Hospitals
AustraliaJulian Castro, Ioana Arhanghelschi, Andrew Buettner
GE HealthcareTransthoracic echocardiography
University of Cape TownVisiting Scholar Fund
Study participants
Human research ethics committee
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Stroke volume
Characteristic AustraliaUntreated
severe preeclampsia
n = 19
South AfricaUntreated
severe preeclampsia
n = 15
P value
LVOT diameter (cm) 1.96 ± 0.12 2.07 ± 0.21 0.077
LVOT VTI (cm) 19.7 ± 3.6 23.7 ± 5.6 0.025
LVOT VTI time (msec) 295 ± 35.6 326 ± 30.2 0.011
LVOT VTI time/average cardiac cycle time 0.39 ± 0.05 0.45 ± 0.08 0.025
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Interobserver variabilityLeft ventricular outflow tract diameter
n=40
1.6 1.8 2.0 2.2 2.4-0.3
-0.2
-0.1
-0.0
0.1
0.2
0.3
LVOTd = left ventricular outflow tract diameterMean difference = -0.003 cmStandard deviation (SD) = 0.099 cm
Upper limit = mean + 1.96SD = 0.197 cm
Lower limit = mean - 1.96SD = -0.197 cmMean LVOTd = 1.99 cm95% interobserver measurements are within 0.20 cm (10 %) of meanLVOTd
Upper limit
Lower limit
Mean difference
Average LVOTd (cm)
Dif
fere
nce L
VO
Td
1 -
LV
OT
d2 (
cm
)
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Interobserver variabilityLeft ventricular outflow tract velocity time integral
n=40
10 15 20 25 30 35-4
-2
0
2
4
VTI = velocity time integralMean difference = -0.251 cm/sStandard deviation (SD) = 1.17 cm/s
Upper limit = mean + 1.96SD = 2.03 cm/s
Lower limit = mean - 1.96SD = -2.53 cm/sMean VTI = 21.15 cm/s95% interobserver measurements are within 2.3 cm/s (11%) of mean VTI
Upper limit
Lower limit
Mean difference
Average VTI (cm/s)
Dif
fere
nce -
VT
I1 -
VT
I2 (
cm
)
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PLAX PSAX
A4C