Mette-Elise Estensen

Changes in blood pressure during healthy pregnancy: a longitudinal cohort study.

Objective: To study longitudinally changes in blood pressure (BP) and heart rate (HR) during healthy pregnancies and to evaluate the influence of parity, pregestational overweight, and excessive weight gain. Methods: A prospective longitudinal cohort study of 57 healthy white women with singleton pregnancies. BP and HR were measured repeatedly at gestational age 14–16 weeks, 22–24 weeks, 30–32 weeks, 36 weeks, and 6 months postpartum using both an oscillometric measurement device (Dinamap) and finger arterial pressure (Finometer PRO). Results: SBP, DBP, and mean arterial pressure (MAP) reached a statistically significant trough at gestational age 22–24 weeks using both measurement devices. When compared with the nonpregnant measurement, SBP at gestational age 22–24 weeks was 6.2 mmHg [95% confidence interval (95% CI) 1.3–11.2] lower measured by Finometer and 7.2 mmHg (95% CI 4.2–10.1) lower measured by Dinamap. DBP and MAP were 8.9 mmHg (95% CI 4.6–13.2) and 9.8 mmHg (95% CI 5.3–14.2) lower measured by Finometer. Measured by Dinamap, DBP and MAP were 4.5 mmHg (95% CI 1.7–7.3) and 5.4 mmHg (95% CI 2.8–7.9) lower at gestational age 22–24 weeks when compared with the nonpregnant state. SBP was significantly higher in women with pregestational BMI at least 25 kg/m2 with both measurement devices (both P < 0.05). There were no differences in SBP, DBP, or MAP depending on parity or excessive weight gain. Conclusion: BP measured repeatedly by two different noninvasive devices during pregnancy and postpartum showed a statistically significant drop in mid-pregnancy, followed by a progressive increase until term.

Altered maternal left ventricular contractility and function during normal pregnancy.

To evaluate maternal left ventricular (LV) systolic and diastolic function during normal pregnancy by non‐invasive measures of LV contractility incorporating loading conditions.

Increased Arterial Stiffness in Pre-eclamptic Pregnancy at Term and Early and Late Postpartum: A Combined Echocardiographic and Tonometric Study

BACKGROUND Pre-eclampsia (PE) is characterized by hypertension and proteinuria, and complicates from 3%-10% of all pregnancies. The hemodynamic pathophysiology of the heart and systemic arteries in pre-eclamptic patients has not been well described. We therefore performed a comprehensive comparison of the systemic arterial properties at term and at 6 months postpartum in women with PE and in women with normal pregnancy (NP) and in nonpregnant women with a previous pre-eclamptic pregnancy (PPEP). METHODS The comparison included 40 patients with PE, 40 others with a PPEP (at 3.5±1.0 years postpartum), and 65 women who had had an NP. Noninvasive estimates of blood flow and pressure in the aortic root were made with echocardiography and calibrated right subclavian artery pulse traces obtained through tonometry. Total arterial compliance (C), arterial elastance (Ea), characteristic impedance (Z0), and peripheral arterial resistance (R) were estimated both through the use of a three-element Windkessel model and Fourier analysis of pressure and flow data. RESULTS At term, Z0, Ea, and R were higher by 37%, 25%, and 23%, respectively (all P < 0.05) in women with PE than in those with an NP, and C was lower by 12% (P < 0.05). The values of Z0, Ea, and R remained elevated at 6 months postpartum in women who had had PE, and were also elevated in those with a PPEP, as compared to their values in NP. CONCLUSIONS Our results demonstrate that pre-eclamptic pregnancies are characterized by a higher resistance throughout the arterial system. The altered arterial properties (Ea, Z0, and R) persisted at 6 months after PE and were also elevated at 3 years postpartum in women with a PPEP, indicating that PE induces long-standing cardiovascular disturbances.

Changes in pulmonary function during pregnancy: a longitudinal cohort study

Please cite this paper as: Grindheim G, Toska K, Estensen M, Rosseland L. Changes in pulmonary function during pregnancy: a longitudinal cohort study. BJOG 2012;119:94–101.

Elevated inflammatory markers in preeclamptic pregnancies, but no relation to systemic arterial stiffness

OBJECTIVES To investigate if circulating markers of systemic and vascular inflammation are associated with systemic arterial properties at term and 6months post-partum in women with preeclampsia (PE) and normal pregnancy (NP). STUDY DESIGN Longitudinal, sampling at term and 6months post-partum in 34 women (32±6years) with PE and 61 women (32±5years) with NP. MAIN OUTCOME MEASURES Circulating markers related to systemic and vascular inflammation were measured by enzyme immune-assay. Systemic arterial properties were estimated by Doppler (transthoracic echocardiography) and calibrated right subclavian artery pulse traces. RESULTS CXCL16, soluble tumor necrosis factor receptor type 1 (sTNF-R1), monocyte chemoattractant peptide 1, pentraxin 3 and soluble vascular adhesion molecule 1 (sVCAM-1) were elevated at term in PE, and sTNF-R1 remained elevated 6months post partum compared to NP. However, apart from a negative correlation between mean arterial pressure and sTNF-R1 and sVCAM-1 at term, no associations between systemic and vascular inflammatory markers and systemic arterial properties as reflected by characteristic impedance and arterial elastance, representing proximal aortic stiffness and effective arterial elastance, were found at any time point. CONCLUSIONS Preeclamptic pregnancies are characterized by increased circulating levels of systemic and vascular inflammatory markers. However, these are not associated with systemic arterial properties at term or 6months post partum.

Systemic arterial response and ventriculo–arterial interaction during normal pregnancy

BACKGROUND During normal pregnancy (NP), cardiac output (CO) increases, and blood pressure and systemic vascular resistance are reduced. We wanted to evaluate systemic arterial properties and interaction between the left ventricle (LV) and systemic arteries during NP. The role of systemic arteries and their interaction with LV-function in this hemodynamic response, lack description. METHODS We used noninvasive methods to study 65 healthy women (32 ± 5 years) with NP repeatedly at gestational weeks 14-16, 22-24, 36, and 6 months postpartum (PP). Aortic root pressure and flow were obtained by calibrated right subclavian artery pulse traces and aortic annular Doppler flow recordings. Arterial properties were described by estimates of total arterial compliance (C), proximal aortic stiffness (characteristic impedance (Z(0))), arterial elastance (Ea), and peripheral arterial resistance (R). Ventriculo-arterial coupling (VAC) was characterized by the ratio between arterial (E(a)I) and LV (E(LV)I) elastance index. RESULTS During NP, CO increased by 20% due to increased heart rate and stroke volume. Mean arterial pressure was reduced by 10% (P < 0.001) as compared to 6 months PP. R was reduced by 5% (P < 0.01), Z(0) trended lower and C higher. E(a)I decreased (P < 0.01) and E(LV)I was reduced to a higher extent resulting in 29% increase of E(a)I/E(LV)I during NP (P < 0.01). CONCLUSIONS During NP there is an increase in CO, and decrease in blood pressure and R whereas central aortic properties are less altered. The increased VAC index (E(a)I/E(LV)I) during NP indicates a decrease in LV-function not fully compensated for by vascular adaptation.

Subclinical atherosclerosis in patients with cyanotic congenital heart disease

INTRODUCTION Survival in patients with cyanotic congenital heart disease (CCHD) has improved dramatically. The result is an ageing population with risk of acquired heart disease. Previous small uncontrolled studies suggested that these patients are protected against the development of atherosclerosis. To test this hypothesis, we sought to determine the prevalence of subclinical atherosclerosis in a larger population of patients with CCHD. METHOD We compared the prevalence of subclinical atherosclerosis in adult CCHD patients from Denmark, Sweden, Norway and Australia, with that in age-, sex-, smoking status-, and body mass index matched controls. Coronary artery atherosclerosis was assessed on computed tomography with coronary artery calcification (CAC) score. Subclinical atherosclerosis was defined by CAC-score > 0. Carotid artery atherosclerosis was evaluated using ultrasound by measuring carotid plaque thickness (cPT-max) and carotid intima media thickness (CIMT). Lipid status was evaluated as an important atherosclerotic risk factor. RESULTS Seventy-four patients with CCHD (57% women, median age 49.5 years) and 74 matched controls (57% women, median age 50.0 years) were included. There were no differences between the groups in: CAC-score > 0 (21% vs. 19%, respectively; p = 0.8), carotid plaques (19% vs. 9%, respectively; p = 0.1), cPT-max (2.3 mm vs. 2.8 mm, respectively; p = 0.1) or CIMT (0.61 mm vs. 0.61 mm, respectively; p = 0.98). And further no significant differences in lipoprotein concentrations measured by ultracentrifugation. CONCLUSION Young adults with CCHD have similar cardiovascular risk factor profiles and measures of subclinical atherosclerosis, compared with controls. Given their increasing life expectancies, athero-preventive strategies should be an important part of their clinical management.

Predictors of Death in Contemporary Adult Patients With Eisenmenger Syndrome

Background: Eisenmenger syndrome is associated with substantial morbidity and mortality. There is no consensus, however, on mortality risk stratification. We aimed to investigate survival and predictors of death in a large, contemporary cohort of Eisenmenger syndrome patients. Methods: In a multicenter approach, we identified adults with Eisenmenger syndrome under follow-up between 2000 and 2015. We examined survival and its association with clinical, electrocardiographic, echocardiographic, and laboratory parameters. Results: We studied 1098 patients (median age, 34.4 years; range, 16.1–84.4 years; 65.1% female; 31.9% with Down syndrome). The majority had a posttricuspid defect (n=643, 58.6%), followed by patients with a complex (n=315, 28.7%) and pretricuspid lesion (n=140, 12.7%). Over a median follow-up of 3.1 years (interquartile range, 1.4–5.9), allowing for 4361.6 patient-years observation, 278 patients died and 6 underwent transplantation. Twelve parameters emerged as significant predictors of death on univariable analysis. On multivariable Cox regression analysis, only age (hazard ratio [HR], 1.41/10 years; 95% confidence interval [CI], 1.24–1.59; P<0.001), pretricuspid shunt (HR, 1.56; 95% CI, 1.02–2.39; P=0.041), oxygen saturation at rest (HR, 0.53/10%; 95% CI, 0.43–0.65; P<0.001), presence of sinus rhythm (HR, 0.53; 95% CI, 0.32–0.88; P=0.013), and presence of pericardial effusion (HR, 2.41; 95% CI, 1.59–3.66; P<0.001) remained significant predictors of death. Conclusions: There is significant premature mortality among contemporary adults with Eisenmenger syndrome. We report, herewith, a multivariable mortality risk stratification model based on 5 simple, noninvasive predictors of death in this population.

Predictors of Death in Contemporary Adult Patients With Eisenmenger SyndromeClinical Perspective

Background: Eisenmenger syndrome is associated with substantial morbidity and mortality. There is no consensus, however, on mortality risk stratification. We aimed to investigate survival and predictors of death in a large, contemporary cohort of Eisenmenger syndrome patients. Methods: In a multicenter approach, we identified adults with Eisenmenger syndrome under follow-up between 2000 and 2015. We examined survival and its association with clinical, electrocardiographic, echocardiographic, and laboratory parameters. Results: We studied 1098 patients (median age, 34.4 years; range, 16.1–84.4 years; 65.1% female; 31.9% with Down syndrome). The majority had a posttricuspid defect (n=643, 58.6%), followed by patients with a complex (n=315, 28.7%) and pretricuspid lesion (n=140, 12.7%). Over a median follow-up of 3.1 years (interquartile range, 1.4–5.9), allowing for 4361.6 patient-years observation, 278 patients died and 6 underwent transplantation. Twelve parameters emerged as significant predictors of death on univariable analysis. On multivariable Cox regression analysis, only age (hazard ratio [HR], 1.41/10 years; 95% confidence interval [CI], 1.24–1.59; P<0.001), pretricuspid shunt (HR, 1.56; 95% CI, 1.02–2.39; P=0.041), oxygen saturation at rest (HR, 0.53/10%; 95% CI, 0.43–0.65; P<0.001), presence of sinus rhythm (HR, 0.53; 95% CI, 0.32–0.88; P=0.013), and presence of pericardial effusion (HR, 2.41; 95% CI, 1.59–3.66; P<0.001) remained significant predictors of death. Conclusions: There is significant premature mortality among contemporary adults with Eisenmenger syndrome. We report, herewith, a multivariable mortality risk stratification model based on 5 simple, noninvasive predictors of death in this population.

Predictors of Death in Contemporary Adult Patients With Eisenmenger SyndromeClinical Perspective: A Multicenter Study

Background: Eisenmenger syndrome is associated with substantial morbidity and mortality. There is no consensus, however, on mortality risk stratification. We aimed to investigate survival and predictors of death in a large, contemporary cohort of Eisenmenger syndrome patients. Methods: In a multicenter approach, we identified adults with Eisenmenger syndrome under follow-up between 2000 and 2015. We examined survival and its association with clinical, electrocardiographic, echocardiographic, and laboratory parameters. Results: We studied 1098 patients (median age, 34.4 years; range, 16.1–84.4 years; 65.1% female; 31.9% with Down syndrome). The majority had a posttricuspid defect (n=643, 58.6%), followed by patients with a complex (n=315, 28.7%) and pretricuspid lesion (n=140, 12.7%). Over a median follow-up of 3.1 years (interquartile range, 1.4–5.9), allowing for 4361.6 patient-years observation, 278 patients died and 6 underwent transplantation. Twelve parameters emerged as significant predictors of death on univariable analysis. On multivariable Cox regression analysis, only age (hazard ratio [HR], 1.41/10 years; 95% confidence interval [CI], 1.24–1.59; P<0.001), pretricuspid shunt (HR, 1.56; 95% CI, 1.02–2.39; P=0.041), oxygen saturation at rest (HR, 0.53/10%; 95% CI, 0.43–0.65; P<0.001), presence of sinus rhythm (HR, 0.53; 95% CI, 0.32–0.88; P=0.013), and presence of pericardial effusion (HR, 2.41; 95% CI, 1.59–3.66; P<0.001) remained significant predictors of death. Conclusions: There is significant premature mortality among contemporary adults with Eisenmenger syndrome. We report, herewith, a multivariable mortality risk stratification model based on 5 simple, noninvasive predictors of death in this population.