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Canadian Journal of Cardiology

Assessing Cardiac Risk in Pregnant Women With Heart Disease: How Risk Scores Are Created and Their Role in Clinical Practice

  • Rohan D. D’Souza
    Affiliations
    Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada

    Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
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  • Candice K. Silversides
    Affiliations
    University of Toronto Pregnancy and Heart Disease and Obstetric Medicine Program, Toronto, Ontario, Canada

    Division of Cardiology, University of Toronto, Toronto, Ontario, Canada
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  • George A. Tomlinson
    Affiliations
    Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, Ontario, Canada

    Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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  • Samuel C. Siu
    Correspondence
    Corresponding author: Dr Samuel Siu, B6-121, University Hospital LHSC, 339 Windermere Road, London, Ontario N6A 5A5, Canada. Tel.: +1-519-663-3581; fax: +1-519-434-3278.
    Affiliations
    University of Toronto Pregnancy and Heart Disease and Obstetric Medicine Program, Toronto, Ontario, Canada

    Division of Cardiology, University of Toronto, Toronto, Ontario, Canada

    Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, Ontario, Canada

    Division of Cardiology, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
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Published:February 24, 2020DOI:https://doi.org/10.1016/j.cjca.2020.02.079

      Abstract

      Pregnancy, which is associated with profound cardiovascular changes and higher risk of thrombosis, increases the risk of cardiovascular complications in women with pre-existing heart disease. A comprehensive history and physical examination, 12-lead electrocardiogram, and transthoracic echocardiogram remain the foundation of assessing cardiac risk during pregnancy in women with heart disease. These are often combined to generate risk scores, which are statistically derived. Several statistically derived risk and 1 lesion-specific classification system are currently available. A suggested clinical approach to risk stratification is first to identify pregnancies in women with cardiac lesions at risk for serious or life-threatening maternal cardiac complications and for the remainder to use the Cardiac Disease in Pregnancy II (CARPREG II) risk score, integrating additional lesion-specific and patient-specific information. Conversely, clinicians can use the modified World Health Organization (mWHO) risk classification system and integrate general risk predictors and patient-specific information. Importantly, cardiac-risk assessment should always incorporate clinical judgement in addition to the use of risk scores or risk-classification systems. As pregnant women with heart disease are also at risk for obstetric and fetoneonatal complications, risk assessment should be performed by a multidisciplinary team, preferably before conception, or as soon as conception is confirmed, and repeated at regular intervals during the course of pregnancy.

      Résumé

      La grossesse, qui est associée à des modifications cardiovasculaires importantes et à un risque plus élevé de thrombose, augmente le risque de complications cardiovasculaires chez les femmes déjà atteintes d’une cardiopathie. L’anamnèse et l’examen physique approfondis, l’électrocardiogramme à 12 dérivations et l’échocardiographie transthoracique demeurent le fondement de l’évaluation du risque cardiaque durant la grossesse des femmes atteintes d’une cardiopathie. Ils sont souvent combinés pour générer des scores de risque, qui sont établis à partir de statistiques. Plusieurs systèmes de classification des risques et 1 système de classification des lésions établis à partir de statistiques sont actuellement disponibles. L’approche clinique proposée pour la stratification du risque consiste d’abord à repérer les femmes enceintes ayant des lésions cardiaques qui sont exposées à des complications maternelles sérieuses ou qui mettent en danger leur vie, et ensuite à utiliser le score de risque CARPREG II (Cardiac Disease in Pregnancy II), qui intègre des informations supplémentaires propres à ces lésions et à ces patientes. En contrepartie, les cliniciens peuvent utiliser la révision du système de classification de l’Organisation mondiale de la Santé (rOMS) et intégrer les prédicteurs de risque généraux et les informations sur la patiente. Notamment, l’évaluation du risque cardiaque devrait toujours tenir compte du jugement clinique en plus d’utiliser les scores de risque ou les systèmes de classification des risques. Puisque les femmes enceintes atteintes d’une cardiopathie sont également exposées aux risques de complications obstétricales, fœtales et néonatales, l’évaluation des risques devrait être réalisée par une équipe multidisciplinaire, de préférence avant la conception, ou aussitôt que la conception est confirmée, et répétée à des intervalles réguliers au cours de la grossesse.
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