Cardiac Structure, Function and Mechanics in Hypertensive Disorders of Pregnancy: A Systematic Review and Meta-Analysis

Abstract

Background: Hypertensive disorders of pregnancy (HDP) are among the most common pregnancy complications and leading causes of maternal morbidity and mortality worldwide. This study aimed to perform the largest meta-analysis to date comparing conventional and advanced echocardiographic features in HDP against healthy pregnancy.

Methods: PubMed (MEDLINE) and EMBASE were systematically searched for research articles published up to March 2024. Included studies reported at least 1 relevant echocardiographic parameter in pregnancies complicated by HDP and normotensive healthy pregnancies separately. A total of 53 studies met the inclusion criteria, comprising 7168 participants (3381 HDP and 3787 controls).

Results: Myocardial mechanics, as measured by global longitudinal strain (weighted mean difference (WMD), -2.81% [95% CI, -3.70 to -1.91]; P<0.001) and left atrial reservoir strain (WMD, -9.36% [95% CI, -12.73 to -5.99]; P<0.001), were significantly impaired in HDP compared with healthy pregnancy. Furthermore, there were prominent cardiac structural differences, with significantly greater left ventricular mass index (WMD, 12.20 [95% CI, 9.77-14.64]; P<0.001), relative wall thickness (WMD, 0.055 [95% CI, 0.04-0.07]; P<0.001), left atrial size (WMD, 2.34 cm [95% CI, 1.62-3.06]; P<0.001), and left atrial volume index (WMD, 2.38 mL/m² [95% CI, 1.44-3.32]; P<0.001) in HDP compared with healthy pregnancy. Finally, the ratio between early mitral inflow velocity and early mitral annular velocity average was significantly greater in HDP (WMD, 1.90 [95% CI, 1.42-2.38; P<0.001), indicative of an elevated left ventricular filling pressure.

Conclusions: This meta-analysis highlights clinically relevant differences in echocardiographic measures between HDP and healthy pregnancy. These results may enhance the utilization of echocardiography for the risk stratification and management of women with HDP. Advanced myocardial mechanics, including global longitudinal strain and left atrial reservoir strain, likely play a key role in detecting subclinical myocardial dysfunction and guidance for early intervention.

Keywords: echocardiography; humans; hypertension, pregnacy-induced; pregnancy; risk assessment.