Cardiac structure, function and mechanics in hypertensive disorders of pregnancy: A systematic review and meta-analysis

Journal article

Edwards, J.J, Giorgione, V., Griffiths, M., Compton, C., Greenhough, E., Smith,E., Cunliffe, E., Jalaludeen, N., Yates, T., Meek, C, Cheriyan, J., Marciniak, A, Thilaganathan, B., Sharma, R. and O'Driscoll, J. 2025. Cardiac structure, function and mechanics in hypertensive disorders of pregnancy: A systematic review and meta-analysis . Hypertension. 82, pp. 00-00. https://doi.org/10.1161
AuthorsEdwards, J.J, Giorgione, V., Griffiths, M., Compton, C., Greenhough, E., Smith,E., Cunliffe, E., Jalaludeen, N., Yates, T., Meek, C, Cheriyan, J., Marciniak, A, Thilaganathan, B., Sharma, R. and O'Driscoll, J.
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.

KeywordsEchocardiography; Heart atria; Humans; Pregnancy; Risk assessment
Year2025
JournalHypertension
Journal citation82, pp. 00-00
PublisherLippincott, Williams and Wilkins
ISSN0194911X, 15244563
Digital Object Identifier (DOI)https://doi.org/10.1161
Official URLhttps://www.ahajournals.org/doi/10.1161/HYPERTENSIONAHA.124.24472
Publication dates
Online14 May 2025
Publication process dates
AcceptedApr 2025
Deposited02 Jun 2025
Accepted author manuscript
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Open
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McCarthy, F., O'Driscoll, J., Seed, P., Brockbank, A., Cox, A., Gill, C., Green, M., Marber, M., Poston, L., Placzek, A., Shennan, A., Sparkes, J., Leeson, P., Thilaganathan, B. and Chappell, L. 2021. Planned delivery to improve postpartum cardiac function in women with preterm pre-eclampsia: the PHOEBE mechanisms of action study within the PHOENIX RCT. Efficacy and Mechanism Evaluation. 8 (12), pp. 1-28. https://doi.org/10.3310/eme08120
Multicenter cohort study, with a nested randomized comparison, to examine the cardiovascular impact of preterm preeclampsia
McCarthy, F.P., O'Driscoll, J., Seed, P.T., Placzek, A., Gill, C., Sparkes, J., Poston, L., Marber, M., Shennan, A.H., Thilaganathan, B., Leeson, P. and Chappell, L.C. 2021. Multicenter cohort study, with a nested randomized comparison, to examine the cardiovascular impact of preterm preeclampsia. Hypertension. https://doi.org/10.1161/HYPERTENSIONAHA.121.17171
Risk of atrial fibrillation in athletes: a systematic review and meta-analysis.
Newman, William, Parry-Williams, Gemma, Wiles, Jonathan, Edwards, Jamie, Hulbert, Sabina, Kipourou, Konstantina, Papadakis, Michael, Sharma, Rajan and O'Driscoll, Jamie 2021. Risk of atrial fibrillation in athletes: a systematic review and meta-analysis. British Journal of Sports Medicine. https://doi.org/bjsports-2021-103994
Validity and reliability of RPE as a measure of intensity during isometric wall squat exercise
Lea, J., O'Driscoll, J., Coleman, D. and Wiles, J. 2021. Validity and reliability of RPE as a measure of intensity during isometric wall squat exercise. Journal of Clinical and Translational Research. 7 (2), pp. 248-256. https://doi.org//10.18053/jctres.07.202102.007
Validity and reliability of the ‘Isometric Exercise Scale’ (IES) for measuring ratings of perceived exertion during continuous isometric exercise
Lea, J., O'Driscoll, J., Coleman, D. and Wiles, J. 2021. Validity and reliability of the ‘Isometric Exercise Scale’ (IES) for measuring ratings of perceived exertion during continuous isometric exercise. Scientific Reports. 11 (5334). https://doi.org/10.1038/s41598-021-84803-8
Real-world performance and accuracy of stress echocardiography: the EVAREST observational multi-centre study
Woodward, W., Dockerill, Cameron, McCourt, Annabelle, Upton, Ross, O'Driscoll, Jamie, Balkhausen, Katrin, Chandrasekaran, Badrinathan, Firoozan, Soroosh, Kardos, Attila, Wong, Kenneth, Woodward, Gary, Sarwar, Rizwan, Sabharwal, N., Benedetto, Elena, Spagou, Nancy, Sharma, Rajan, Augustine, Daniel, Tsiachristas, Apostolos, Senior, R., Leeson, P., Boardman, Henry, d’Arcy, Joanna, Abraheem, Abraheem, Banypersad, Sanjay, Boos, Christopher, Bulugahapitiya, Sudantha, Butts, Jeremy, Coles, Duncan, Easaw, Jacob, Hamdan, Haytham, Jamil-Copley, Shahnaz, Kanaganayagam, Gajen, Mwambingu, Tom, Pantazis, Antonis, Papachristidis, Alexandros, Rajani, Ronak, Rasheed, Muhammad Amer, Razvi, Naveed A, Rekhraj, Sushma, Ripley, David P, Rose, Kathleen, Scheuermann-Freestone, Michaela, Schofield, Rebecca and Sultan, Ayyaz 2021. Real-world performance and accuracy of stress echocardiography: the EVAREST observational multi-centre study. European Heart Journal - Cardiovascular Imaging. 23 (5), pp. 689-698. https://doi.org/10.1093/ehjci/jeab092
Continuous cardiac autonomic and haemodynamic responses to isometric exercise in females
O'Driscoll, J., Boucher, C., Vilda, M., Taylor, K. and Wiles, J. 2020. Continuous cardiac autonomic and haemodynamic responses to isometric exercise in females. European Journal of Applied Physiology and Occupational Physiology. https://doi.org/10.1007/s00421-020-04525-z
Ambulatory blood pressure adaptations to high-intensity interval training: a randomized controlled study
Edwards, J., Taylor, K.A., Cottam, C., Jalaludeen, N., Coleman, D.A., Wiles, J.D., Sharma, R. and O'Driscoll, J.M. 2020. Ambulatory blood pressure adaptations to high-intensity interval training: a randomized controlled study. Journal of Hypertension. https://doi.org/10.1097/HJH.0000000000002630
Centre of pressure, vertical ground reaction forces and neuromuscular responses of special-forces soldiers to 43km load carriage in the field
Scales, J., O'Driscoll, J., Coleman, D., Giannoglou, D, Gkougkoulis, I, Ntontis, I, Zisopoulou, C and Brown, M. 2020. Centre of pressure, vertical ground reaction forces and neuromuscular responses of special-forces soldiers to 43km load carriage in the field. Journal of Applied Biomechanics. 36 (5), pp. 307-312. https://doi.org/10.1123/jab.2019-0283
Left atrial mechanics and aortic stiffness following high intensity interval training: a randomised controlled study
Jalaludeen, N., Bull, S., Taylor, K. A., Wiles, J., Coleman, D., Mukhtar, O., Cheriyan, J., Wilkinson, I.B., Sharma, R. and O'Driscoll, J. 2020. Left atrial mechanics and aortic stiffness following high intensity interval training: a randomised controlled study. European Journal of Applied Physiology. https://doi.org/10.1007/s00421-020-04416-3
Differentiation between athlete’s heart and dilated cardiomyopathy in athletic individuals
Millar, L. M., Fanton, Z., Finnochiaro, G., Sanchez-Fernandez, G., Dhutia, H., Malhotra, A., Merghani, A., Papadakis, M., Behr, E. R., Bunce, N., Oxborough, D., Reed, M., O'Driscoll, J., Tome Esteban, M. T., D'Silva, A., Carr-White, G., Sharma, R. and Sharma, S. 2020. Differentiation between athlete’s heart and dilated cardiomyopathy in athletic individuals. Heart. https://doi.org/10.1136/heartjnl-2019-316147
The impact of demographic, anthropometric and athletic characteristics on left atrial size in athletes.
O'Driscoll, J. and Christou, G. 2020. The impact of demographic, anthropometric and athletic characteristics on left atrial size in athletes. Clinical Cardiology. 43 (8), pp. 834-842. https://doi.org/10.1002/clc.23368
Speckle tracking echocardiography: new ways of translational approaches in preeclampsia to detect cardiovascular dysfunction
Kraker, K., Schutte, T., O'Driscoll, J., Birukov, A., Patey, O., Herse, F., Muller, D.N., Thilaganathan, B., Haase, N. and Dechend, R. 2020. Speckle tracking echocardiography: new ways of translational approaches in preeclampsia to detect cardiovascular dysfunction. International Journal of Molecular Sciences. 21 (3). https://doi.org/10.3390/ijms21031162
Challenge and threat: a critical review of the literature and an alternative conceptualization
Uphill, M., Rossato, C., Swain, J. and O'Driscoll, J. 2019. Challenge and threat: a critical review of the literature and an alternative conceptualization. Frontiers in Psychology. https://doi.org/10.3389/fpsyg.2019.01255
Cardiac structure and function after revascularization versus medical therapy for renal artery stenosis: the ASTRAL heart echocardiographic sub-study
Green, D., Vassallo, D., Handley, K., Ives, N., Wheatley, K., Chrysochou, C., Hegarty, J., Wright, J., Moss, J., Patel, R., Deighan, C., Webster, J., Rowe, P., Carr, S., Cross, J., O'Driscoll, J., Sharma, R., Mark, P. and Kalra, P. 2019. Cardiac structure and function after revascularization versus medical therapy for renal artery stenosis: the ASTRAL heart echocardiographic sub-study. BMC Nephrology. https://doi.org/10.1186/s12882-019-1406-y
Characteristics of torque production of the lower limb are significantly altered after 2 hours of treadmill load carriage
Scales, J., Coleman, D., O'Driscoll, J. and Brown, M. 2018. Characteristics of torque production of the lower limb are significantly altered after 2 hours of treadmill load carriage. Translational Sports Medicine. 2 (1). https://doi.org/10.1002/tsm2.54
The impact of gestational diabetes on maternal cardiac adaptation to pregnancy.
Buddeberg, B.S., Sharma, R., O'Driscoll, J., Kaelin, A., Khalil, A. and Thilaganathan, B. 2019. The impact of gestational diabetes on maternal cardiac adaptation to pregnancy. Ultrasound in Obstetrics and Gynecology. https://doi.org/10.1002/uog.21941
Statins Reverse Postpartum Cardiovascular Dysfunction in a Rat Model of Preeclampsia
Kräker, Kristin, O’Driscoll, Jamie M., Schütte, Till, Herse, Florian, Patey, Olga, Golic, Michaela, Geisberger, Sabrina, Verlohren, Stefan, Birukov, Anna, Heuser, Arnd, Müller, Dominik N., Thilaganathan, Basky, Dechend, Ralf and Haase, Nadine 2019. Statins Reverse Postpartum Cardiovascular Dysfunction in a Rat Model of Preeclampsia. Hypertension. 75 (1), pp. 202-210. https://doi.org/10.1161/hypertensionaha.119.13219
Left ventricular function and cardiac biomarker release – the influence of exercise intensity, duration and mode: a systematic review and meta-analysis
Donaldson, J., Wiles, J., Coleman, D., Papadakis, M., Sharma, R. and O'Driscoll, J. 2019. Left ventricular function and cardiac biomarker release – the influence of exercise intensity, duration and mode: a systematic review and meta-analysis. Sports Medicine. https://doi.org/10.1007/s40279-019-01142-5
Cardiac maladaptation in obese pregnancy at term
Buddeberg, B., Sharma, R., O'Driscoll, J., Kaelin Agten, A., Khalil, A. and Thilaganathan, B. 2018. Cardiac maladaptation in obese pregnancy at term. Ultrasound in Obstetrics and Gynecology. https://doi.org/10.1002/uog.20170
A 4-week resistance training intervention improves stability, strength and neuromuscular activity in the lower limb: a case study of a cerebral palsy adult
McManus, A., Bembridge, M., Scales, J., Wiles, J., Coleman, D. and O'Driscoll, J. 2018. A 4-week resistance training intervention improves stability, strength and neuromuscular activity in the lower limb: a case study of a cerebral palsy adult. International Journal of Sports Science & Medicine. 2 (2), pp. 050-055.
Neurohumoral and ambulatory haemodynamic adaptations following isometric exercise training in unmedicated hypertensive patients
Taylor, K., Wiles, J., Coleman, D., Leeson, P., Sharma, R. and O'Driscoll, J. 2018. Neurohumoral and ambulatory haemodynamic adaptations following isometric exercise training in unmedicated hypertensive patients. Journal of Hypertension. https://doi.org/10.1097/HJH.0000000000001922
Cardiac autonomic and left ventricular mechanics following high intensity interval training: a randomised cross-over controlled study.
O'Driscoll, J., Wrigth, S., Taylor, K., Coleman, D., Sharma, R. and Wiles, J. 2018. Cardiac autonomic and left ventricular mechanics following high intensity interval training: a randomised cross-over controlled study. Journal of Applied Physiology. https://doi.org/10.1152/japplphysiol.00056.2018
Cardiac maladaptation in term pregnancies with preeclampsia
Buddeberg, B., Sharma, R., O'Driscoll, J., Kaelin Agten, A., Khalil, A. and Thilaganathan, B. 2018. Cardiac maladaptation in term pregnancies with preeclampsia. Pregnancy Hypertension. 13, pp. 198-203. https://doi.org/10.1016/j.preghy.2018.06.015
The safety of isometric exercise: rethinking the exercise prescription paradigm for those with stage 1 hypertension.
Wiles, J., Taylor, K., Coleman, D., Sharma, R. and O'Driscoll, J. 2018. The safety of isometric exercise: rethinking the exercise prescription paradigm for those with stage 1 hypertension. Medicine. 97 (10). https://doi.org/10.1097/MD.0000000000010105
An alternative approach to isometric exercise training prescription for cardiovascular health
Wiles, J., Goldring, N., O'Driscoll, J., Taylor, K. and Coleman, D. 2018. An alternative approach to isometric exercise training prescription for cardiovascular health. Translational Journal of the American College of Sports Medicine. 3 (2), pp. 10-18. https://doi.org/10.1249/TJX.0000000000000052
Baseline mitral regurgitation predicts outcome in patients referred for dobutamine stress echocardiography
O'Driscoll, J., Gargallo-Fernandez, P., Araco, M., Perez-Lopez, M. and Sharma, R. 2017. Baseline mitral regurgitation predicts outcome in patients referred for dobutamine stress echocardiography. International Journal of Cardiovascular Imaging. https://doi.org/10.1007/s10554-017-1163-6
Blood pressure responses to isometric exercise: safety considerations for exercise prescription
Wiles, J., Taylor, K., Coleman, D., Sharma, R. and O'Driscoll, J. 2017. Blood pressure responses to isometric exercise: safety considerations for exercise prescription.
Ambulatory blood pressure responses to home-based isometric exercise training in pre-hypertensive males
Taylor, K., Wiles, J., Coleman, D., Sharma, R. and O'Driscoll, J. 2017. Ambulatory blood pressure responses to home-based isometric exercise training in pre-hypertensive males.
Cardiac autonomic modulation and high intensity interval training in physically inactive men
O'Driscoll, J., Wright, S., Taylor, K., Coleman, D. and Wiles, J. 2017. Cardiac autonomic modulation and high intensity interval training in physically inactive men.
A higher effort-based paradigm in physical activity and exercise for public health: making the case for a greater emphasis on resistance training
Steele, J., Fisher, J., Skivington, M., Dunn, C., Arnold, J., Tew, G., Batterham, A., Nunan, D., O'Driscoll, J., Mann, S., Beedie, C., Jobson, S., Smith, D., Vigotsky, A., Phillips, S., Estabrooks, P. and Winett, R. 2017. A higher effort-based paradigm in physical activity and exercise for public health: making the case for a greater emphasis on resistance training. BMC Public Health. https://doi.org/10.1186/s12889-017-4209-8
Continuous cardiac autonomic and haemodynamic responses to isometric exercise in pre-hypertensive males
Taylor, K., Wiles, J., Coleman, D., Sharma, R. and O'Driscoll, J. 2017. Continuous cardiac autonomic and haemodynamic responses to isometric exercise in pre-hypertensive males. Medicine & Science in Sports & Exercise (MSSE). https://doi.org/10.1249/MSS.0000000000001271
Acute cardiac functional and mechanical responses to isometric exercise in pre-hypertensive males
O'Driscoll, J., Taylor, K., Wiles, J., Coleman, D. and Sharma, R. 2017. Acute cardiac functional and mechanical responses to isometric exercise in pre-hypertensive males. Physiological Reports. https://doi.org/10.14814/phy2.13236
Body mass index mortality paradox in chronic kidney disease patients with suspected cardiac chest pain
O'Driscoll, J., Slee, A. and Sharma, R. 2017. Body mass index mortality paradox in chronic kidney disease patients with suspected cardiac chest pain. Journal of Cachexia, Sarcopenia and Muscle Clinical Reports. 2 (1).
Strongman training – Needs analysis and integration into strength and conditioning programming: part 2.
McManus, A., O'Driscoll, J., Coleman, D. and Wiles, J. 2016. Strongman training – Needs analysis and integration into strength and conditioning programming: part 2. Professional Strength & Conditioning. 44, pp. 7-15.
Strongman training – a rationale for its inclusion in strength & conditioning: part 1
McManus, A., Wiles, J., Coleman, D. and O'Driscoll, J. 2016. Strongman training – a rationale for its inclusion in strength & conditioning: part 1. Professional Strength & Conditioning. 43, pp. 7-18.
Acute cardiac autonomic responses to an incremental isometric exercise test in pre-hypertensive males
Taylor, K., Wiles, J., Coleman, D., Sharma, R. and O'Driscoll, J. 2016. Acute cardiac autonomic responses to an incremental isometric exercise test in pre-hypertensive males.
Transthoracic echocardiography provides important long-term prognostic information in selected patients undergoing endovascular abdominal aortic repair
O'Driscoll, J., Bahia, S., Gravina, A., Di Fino, S., Thompson, M., Karthikesalingam, A., Holt, P. and Sharma, R. 2016. Transthoracic echocardiography provides important long-term prognostic information in selected patients undergoing endovascular abdominal aortic repair. Circulation Cardiovascular Imaging. https://doi.org/10.1161/CIRCIMAGING.115.003557
Reverse left ventricular remodelling - effect of cardiac rehabilitation exercise training in myocardial infarction patients with preserved ejection fraction
McGregor, G., Gaze, D., Oxborough, D., O'Driscoll, J. and Shave, R. 2015. Reverse left ventricular remodelling - effect of cardiac rehabilitation exercise training in myocardial infarction patients with preserved ejection fraction. European Journal of Physcial and Rehabilitation Medicine. 52 (3), pp. 370-378.
The prognostic value of dobutamine stress echocardiography amongst British Indian Asian and Afro-Caribbean patients: a comparison with European white patients
O'Driscoll, J., Rossato, C., Gargallo-Fernandez, P., Araco, M., Giannoglou, D., Sharma, S. and Sharma, R. 2015. The prognostic value of dobutamine stress echocardiography amongst British Indian Asian and Afro-Caribbean patients: a comparison with European white patients. Cardiovascular Ultrasound. 13 (36). https://doi.org/10.1186/s12947-015-0028-1
Non-invasive assessment of the autonomic nervous system
O'Driscoll, J. and Sharma, R. 2015. Non-invasive assessment of the autonomic nervous system. International Journal of Clinical Therapeutics and Diagnosis. 3 (3), pp. 85-91.
Differing autonomic responses to dobutamine stress in the presence and absence of myocardial ischaemia
Sharma, R., O'Driscoll, J., Saha, A., Sritharan, M., Sutton, R. and Rosen, S. 2015. Differing autonomic responses to dobutamine stress in the presence and absence of myocardial ischaemia. The Journal of Physiology. 593 (9), pp. 2171-2184. https://doi.org/10.1113/JP270063
The safety and clinical usefulness of dobutamine stress echocardiography among octogenarians
O'Driscoll, J., Marciniak, A., Ray, K., Schmid, K., Smith, R. and Sharma, R. 2014. The safety and clinical usefulness of dobutamine stress echocardiography among octogenarians. Heart. 2014 (100), pp. 1001-1007. https://doi.org/10.1136/heartjnl-2013-305229
The implementation of problem based learning styles to teach the Coach-Athlete relationship to undergraduate Sport and Exercise Science students
Rossato, C. and O'Driscoll, J. 2013. The implementation of problem based learning styles to teach the Coach-Athlete relationship to undergraduate Sport and Exercise Science students. International Journal of Sport Studies. 3, pp. 859-864.
Differing autonomic responses to dobutamine stress in the presence and absence of myocardial ischaemia
Sharma, R., O'Driscoll, J., Bromley, P., Sritharan, M. and Rosen, S. 2008. Differing autonomic responses to dobutamine stress in the presence and absence of myocardial ischaemia.
Dobutamine stress echocardiography accurately detects significant coronary artery disease in Indian Asians living in the United Kingdom
Itam, S., O'Driscoll, J., Milad, E. and Sharma, R. 2008. Dobutamine stress echocardiography accurately detects significant coronary artery disease in Indian Asians living in the United Kingdom.
The effects of a high-protein, paleolithic-type diet on body composition and exercise performance in amateur mixed martial artists
Slee, A., O'Driscoll, J., Burnet, S., Hughes, G. and Chen, M. 2009. The effects of a high-protein, paleolithic-type diet on body composition and exercise performance in amateur mixed martial artists.
Subjective global assessment is an independent predictor of cardiac ischaemia in patients with mild chronic kidney disease
Aldous, G., Sharma, R., O'Driscoll, J., Ashby, D., Tarn, F. and Choi, P. 2010. Subjective global assessment is an independent predictor of cardiac ischaemia in patients with mild chronic kidney disease.
A National Health Service hospital's cardiac rehabilitation programme: a qualitative analysis of provision
O'Driscoll, J., Shave, R. and Cushion, C. 2007. A National Health Service hospital's cardiac rehabilitation programme: a qualitative analysis of provision. Journal of Clinical Nursing. 16 (10), pp. 1908-1918. https://doi.org/10.1111/j.1365-2702.2007.01815.x
Inequalities in the training and implementation of cardiac rehabilitation in the United Kingdom
O'Driscoll, J. and Sharma, R. 2009. Inequalities in the training and implementation of cardiac rehabilitation in the United Kingdom. in: Bennington, E. (ed.) Horizons in World Cardiovascular Research Hauppauge, New York Nova Science Publishers.