Predictive accuracy of four risk scores for cardiovascular complications during pregnancy in women with congenital heart disease: a systematic review and meta-analysis_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

MA Chenyang ¹ ,  TANG Menglin ²

1. West China School of Nursing, Sichuan University/Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, 610041, P. R. China;
2. West China School of Nursing, Sichuan University/Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, 610041, P. R. China;

Corresponding?author：

TANG Menglin, Email: mengling_tang@163.com

Keywords：

Congenital heart disease; pregnancy; cardiovascular complications; risk scoring system; systematic review/meta-analysis

DOI：

10.7507/1007-4848.202504044

Video：

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Objective To explore the predictive value of four risk scoring systems for cardiovascular complications during pregnancy in patients with congenital heart disease (CHD). Methods Computer searches were conducted in PubMed, EMbase, CENTRAL, Web of Science, China National Knowledge Infrastructure (CNKI), Wanfang Data, VIP, and China Biology Medicine disc (CBM). Relevant studies on risk scoring systems for cardiovascular complications during pregnancy in CHD patients at home and abroad were comprehensively collected. The retrieval period was from the establishment of the databases to January 1, 2025, and the retrieval was updated on March 26, 2025. After two reviewers independently screened the literature and extracted the data, the quality assessment was carried out, and Meta-analysis was performed using MedCalc software. Results A total of 11 studies were included, with a total of 4 987 patients. The incidence of cardiovascular complications during pregnancy in CHD patients ranged from 6.72% to 28.84%. The QUADAS-2 scoring tool results showed that two studies had a risk of bias, and nine studies were determined to have a high risk of bias. The results of the Meta-analysis showed that the CARPREGⅠ score [AUC=0.709, 95%CI (0.672, 0.745), P<0.001], CARPREGⅡ score [AUC=0.757, 95%CI (0.720, 0.794), P<0.001], ZAHARA score [AUC=0.732, 95%CI (0.674, 0.790), P<0.001], and mWHO classification system [AUC=0.681, 95%CI (0.617, 0.745), P<0.001] could independently predict cardiovascular complications during pregnancy in CHD patients. Conclusion The existing evidence indicates that all four scoring systems can be used to predict cardiovascular complications during pregnancy in CHD patients. Although the CARPREGⅡ score has the highest accuracy, the number of included studies is small. It is recommended to give priority to using the ZAHARA score for risk stratification and pregnancy management of women with CHD before pregnancy. In view of the limitations of the quality of the included studies, this study needs to be further confirmed by high-quality studies.

1.	Hua L, Xu JW, Zhao XD, et al. Pregnancy outcomes in women with heart disease. Chin Med J, 2010, 123(17): 2324-2330.
2.	Bottega N, Malhamé I, Guo L, et al. Secular trends in pregnancy rates, delivery outcomes, and related health care utilization among women with congenital heart disease. Congenit Heart Dis, 2019, 14(5): 735-744.
3.	Canobbio MM, Warnes CA, Aboulhosn J, et al. Management of pregnancy in patients with complex congenital heart disease: a scientific statement for healthcare professionals from the American Heart Association. Circulation, 2017, 135(8): e50-e87.
4.	Hardee I, Wright L, McCracken C, et al. Maternal and neonatal outcomes of pregnancies in women with congenital heart disease: a meta-analysis. J Am Heart Assoc, 2021, 10(8): e017834.
5.	Wang TKM, Lowe B, Hlohovsky S, et al. Performance of risk models predicting cardiac complications in pregnant women with congenital heart disease: a meta-analysis. Intern Med J, 2020, 50(4): 481-484.
6.	Roos-Hesselink J, Baris L, Johnson M, et al. Pregnancy outcomes in women with cardiovascular disease: evolving trends over 10 years in the ESC Registry of Pregnancy and Cardiac disease (ROPAC). Eur Heart J, 2019, 40(47): 3848-3855.
7.	D'Souza RD, Silversides CK, Tomlinson GA, et al. Assessing cardiac risk in pregnant women with heart disease: how risk scores are created and their role in clinical practice. Can J Cardiol, 2020, 36(7): 1011-1021.
8.	傅勤. 妊娠合并心臟病患者心血管風險評估系統研究進展. 中國實用婦科與產科雜志, 2016, 32(2): 201-203.Fu Q. Research progress on cardiovascular risk assessment system for pregnant patients with heart disease. Chin J Pract Gynecol Obstet, 2016, 32(2): 201-203.
9.	Siu SC, Sermer M, Colman JM, et al. Prospective multicenter study of pregnancy outcomes in women with heart disease. Circulation, 2001, 104(5): 515-521.
10.	Drenthen W, Boersma E, Balci A, et al. Predictors of pregnancy complications in women with congenital heart disease. Eur Heart J, 2010, 31(17): 2124-2132.
11.	Regitz-Zagrosek V, Blomstrom LC, Borghi C, et al. ESC guidelines on the management of cardiovascular diseases during pregnancy: the task force on the management of cardiovascular diseases during pregnancy of the European Society of Cardiology (ESC). Eur Heart J, 2011, 32(24): 3147-3197.
12.	Silversides CK, Grewal J, Mason J, et al. Pregnancy outcomes in women with heart disease: the CARPREGⅡ study. J Am Coll Cardiol, 2018, 71(21): 2419-2430.
13.	Bredy C, Deville F, Huguet H, et al. Which risk score best predicts cardiovascular outcome in pregnant women with congenital heart disease? Eur Heart J Qual Care Clin Outcomes, 2023, 9(2): 177-183.
14.	Denayer N, Troost E, Santens B, et al. Comparison of risk stratification models for pregnancy in congenital heart disease. Int J Cardiol, 2021, 323: 54-60.
15.	Kim YY, Goldberg LA, Awh K, et al. Accuracy of risk prediction scores in pregnant women with congenital heart disease. Congenit Heart Dis, 2019, 14(3): 470-478.
16.	Lee J, Mulder F, Leeflang M, et al. QUAPAS: an adaptation of the QUADAS-2 tool to assess prognostic accuracy studies. Ann Intern Med, 2022, 175(7): 1010-1018.
17.	張妹, 衛建華, 沈建通, 等. 預后準確性研究偏倚風險評價工具QUAPAS解讀. 中國循證醫學雜志, 2023, 23(4): 457-464.Zhang M, Wei JH, Shen JT, et al. Interpretation of the risk assessment tool QUAPAS for prognostic accuracy studies. Chin J Evid Based Med, 2023, 23(4): 457-464.
18.	Balci A, Sollie-Szarynska KM, Van Der Bijl AG, et al. Prospective validation and assessment of cardiovascular and offspring risk models for pregnant women with congenital heart disease. Heart, 2014, 100(17): 1373-1381.
19.	Pijuan-Domènech A, Galian L, Goya M, et al. Cardiac complications during pregnancy are better predicted with the modified WHO risk score. Int J Cardiol, 2015, 195: 149-154.
20.	Lu CW, Shih JC, Chen SY, et al. Comparison of 3 risk estimation methods for predicting cardiac outcomes in pregnant women with congenital heart disease. Circ J, 2015, 79(7): 1609-1617.
21.	Fu Q, Lin J. Predictive accuracy of three clinical risk assessment systems for cardiac complications among Chinese pregnant women with congenital heart disease. Int J Gynaecol Obstet, 2016, 134(2): 140-144.
22.	楊嘉琳, 余碧琳, 徐仲, 等. 心臟風險評估系統在妊娠合并先天性心臟病中的應用研究. 實用醫學雜志, 2016, 32(12): 1983-1986.Yang JL, Yu BL, Xu Z, et al. Application of different cardiac assessment systems in pregnant women with congenital heart disease. J Pract Med, 2016, 32(12): 1983-1986.
23.	Van Hagen IM, Boersma E, Johnson MR, et al. Global cardiac risk assessment in the Registry of Pregnancy and Cardiac Disease: results of a registry from the European Society of Cardiology. Eur J Heart Fail, 2016, 18(5): 523-533.
24.	Furen?s E, Eriksson P, Wennerholm UB, et al. Effect of maternal age and cardiac disease severity on outcome of pregnancy in women with congenital heart disease. Int J Cardiol, 2017, 243: 197-203.
25.	Fu Q, Wang XJ, Wang BS, et al. Cardiac risk prediction model for pregnant women with structural heart disease in Eastern China. Int J Gynaecol Obstet, 2019, 145(3): 324-330.
26.	Van Hagen IM, Roos-Hesselink JW. Pregnancy in congenital heart disease: risk prediction and counselling. Heart, 2020, 106(23): 1853-1861.
27.	Regitz-Zagrosek V, Roos-Hesselink JW, Bauersachs J, et al. 2018 ESC guidelines for the management of cardiovascular diseases during pregnancy. Kardiol Pol, 2019, 77(3): 245-326.
28.	?orbac?o?lu ?K, Aksel G. Receiver operating characteristic curve analysis in diagnostic accuracy studies: a guide to interpreting the area under the curve value. Turk J Emerg Med, 2023, 23(4): 195-198.
29.	American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 200: cardiovascular disease in pregnancy. Obstet Gynecol, 2018, 132(5): e153-e175.
30.	Elkayam U, Bitar F, Hameed A, et al. Cardiovascular disease in pregnancy: part Ⅲ: recommendations on management. J Am Coll Cardiol, 2016, 68(13): 1447-1460.
31.	Roos-Hesselink JW, Ruys TP, Stein JI, et al. Outcome of pregnancy in patients with structural or ischaemic heart disease: results of a registry of the European Society of Cardiology. Eur Heart J, 2013, 34(9): 657-665.

1. Hua L, Xu JW, Zhao XD, et al. Pregnancy outcomes in women with heart disease. Chin Med J, 2010, 123(17): 2324-2330.
2. Bottega N, Malhamé I, Guo L, et al. Secular trends in pregnancy rates, delivery outcomes, and related health care utilization among women with congenital heart disease. Congenit Heart Dis, 2019, 14(5): 735-744.
3. Canobbio MM, Warnes CA, Aboulhosn J, et al. Management of pregnancy in patients with complex congenital heart disease: a scientific statement for healthcare professionals from the American Heart Association. Circulation, 2017, 135(8): e50-e87.
4. Hardee I, Wright L, McCracken C, et al. Maternal and neonatal outcomes of pregnancies in women with congenital heart disease: a meta-analysis. J Am Heart Assoc, 2021, 10(8): e017834.
5. Wang TKM, Lowe B, Hlohovsky S, et al. Performance of risk models predicting cardiac complications in pregnant women with congenital heart disease: a meta-analysis. Intern Med J, 2020, 50(4): 481-484.
6. Roos-Hesselink J, Baris L, Johnson M, et al. Pregnancy outcomes in women with cardiovascular disease: evolving trends over 10 years in the ESC Registry of Pregnancy and Cardiac disease (ROPAC). Eur Heart J, 2019, 40(47): 3848-3855.
7. D'Souza RD, Silversides CK, Tomlinson GA, et al. Assessing cardiac risk in pregnant women with heart disease: how risk scores are created and their role in clinical practice. Can J Cardiol, 2020, 36(7): 1011-1021.
8. 傅勤. 妊娠合并心臟病患者心血管風險評估系統研究進展. 中國實用婦科與產科雜志, 2016, 32(2): 201-203.Fu Q. Research progress on cardiovascular risk assessment system for pregnant patients with heart disease. Chin J Pract Gynecol Obstet, 2016, 32(2): 201-203.
9. Siu SC, Sermer M, Colman JM, et al. Prospective multicenter study of pregnancy outcomes in women with heart disease. Circulation, 2001, 104(5): 515-521.
10. Drenthen W, Boersma E, Balci A, et al. Predictors of pregnancy complications in women with congenital heart disease. Eur Heart J, 2010, 31(17): 2124-2132.
11. Regitz-Zagrosek V, Blomstrom LC, Borghi C, et al. ESC guidelines on the management of cardiovascular diseases during pregnancy: the task force on the management of cardiovascular diseases during pregnancy of the European Society of Cardiology (ESC). Eur Heart J, 2011, 32(24): 3147-3197.
12. Silversides CK, Grewal J, Mason J, et al. Pregnancy outcomes in women with heart disease: the CARPREGⅡ study. J Am Coll Cardiol, 2018, 71(21): 2419-2430.
13. Bredy C, Deville F, Huguet H, et al. Which risk score best predicts cardiovascular outcome in pregnant women with congenital heart disease? Eur Heart J Qual Care Clin Outcomes, 2023, 9(2): 177-183.
14. Denayer N, Troost E, Santens B, et al. Comparison of risk stratification models for pregnancy in congenital heart disease. Int J Cardiol, 2021, 323: 54-60.
15. Kim YY, Goldberg LA, Awh K, et al. Accuracy of risk prediction scores in pregnant women with congenital heart disease. Congenit Heart Dis, 2019, 14(3): 470-478.
16. Lee J, Mulder F, Leeflang M, et al. QUAPAS: an adaptation of the QUADAS-2 tool to assess prognostic accuracy studies. Ann Intern Med, 2022, 175(7): 1010-1018.
17. 張妹, 衛建華, 沈建通, 等. 預后準確性研究偏倚風險評價工具QUAPAS解讀. 中國循證醫學雜志, 2023, 23(4): 457-464.Zhang M, Wei JH, Shen JT, et al. Interpretation of the risk assessment tool QUAPAS for prognostic accuracy studies. Chin J Evid Based Med, 2023, 23(4): 457-464.
18. Balci A, Sollie-Szarynska KM, Van Der Bijl AG, et al. Prospective validation and assessment of cardiovascular and offspring risk models for pregnant women with congenital heart disease. Heart, 2014, 100(17): 1373-1381.
19. Pijuan-Domènech A, Galian L, Goya M, et al. Cardiac complications during pregnancy are better predicted with the modified WHO risk score. Int J Cardiol, 2015, 195: 149-154.
20. Lu CW, Shih JC, Chen SY, et al. Comparison of 3 risk estimation methods for predicting cardiac outcomes in pregnant women with congenital heart disease. Circ J, 2015, 79(7): 1609-1617.
21. Fu Q, Lin J. Predictive accuracy of three clinical risk assessment systems for cardiac complications among Chinese pregnant women with congenital heart disease. Int J Gynaecol Obstet, 2016, 134(2): 140-144.
22. 楊嘉琳, 余碧琳, 徐仲, 等. 心臟風險評估系統在妊娠合并先天性心臟病中的應用研究. 實用醫學雜志, 2016, 32(12): 1983-1986.Yang JL, Yu BL, Xu Z, et al. Application of different cardiac assessment systems in pregnant women with congenital heart disease. J Pract Med, 2016, 32(12): 1983-1986.
23. Van Hagen IM, Boersma E, Johnson MR, et al. Global cardiac risk assessment in the Registry of Pregnancy and Cardiac Disease: results of a registry from the European Society of Cardiology. Eur J Heart Fail, 2016, 18(5): 523-533.
24. Furen?s E, Eriksson P, Wennerholm UB, et al. Effect of maternal age and cardiac disease severity on outcome of pregnancy in women with congenital heart disease. Int J Cardiol, 2017, 243: 197-203.
25. Fu Q, Wang XJ, Wang BS, et al. Cardiac risk prediction model for pregnant women with structural heart disease in Eastern China. Int J Gynaecol Obstet, 2019, 145(3): 324-330.
26. Van Hagen IM, Roos-Hesselink JW. Pregnancy in congenital heart disease: risk prediction and counselling. Heart, 2020, 106(23): 1853-1861.
27. Regitz-Zagrosek V, Roos-Hesselink JW, Bauersachs J, et al. 2018 ESC guidelines for the management of cardiovascular diseases during pregnancy. Kardiol Pol, 2019, 77(3): 245-326.
28. ?orbac?o?lu ?K, Aksel G. Receiver operating characteristic curve analysis in diagnostic accuracy studies: a guide to interpreting the area under the curve value. Turk J Emerg Med, 2023, 23(4): 195-198.
29. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 200: cardiovascular disease in pregnancy. Obstet Gynecol, 2018, 132(5): e153-e175.
30. Elkayam U, Bitar F, Hameed A, et al. Cardiovascular disease in pregnancy: part Ⅲ: recommendations on management. J Am Coll Cardiol, 2016, 68(13): 1447-1460.
31. Roos-Hesselink JW, Ruys TP, Stein JI, et al. Outcome of pregnancy in patients with structural or ischaemic heart disease: results of a registry of the European Society of Cardiology. Eur Heart J, 2013, 34(9): 657-665.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Latest ArticlesPredictive accuracy of four risk scores for cardiovascular complications during pregnancy in women with congenital heart disease: a systematic review and meta-analysis

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