当代实践中孕产妇心脏风险分层的外部验证
本研究为单中心回顾性队列研究，纳入2009至2023年在一家四级母胎中心分娩的282例心脏病女性共407次妊娠。评估mWHO、CARPREG II和ZAHARA三种风险分层工具对孕产妇心脏并发症的预测效能。结果显示三种模型均高估心脏风险，且均无法预测产科并发症。
要点
- 三种风险评分均高估当代专科队列的孕产妇心脏风险
- 三种评分对心脏并发症的区分度均为中等水平
- 三种评分均不能预测产科并发症
核心结论
- mWHO、CARPREG II和ZAHARA三种评分在当代专科队列中可能高估孕产妇心脏风险，存在校准漂移但保留了临床有意义的风险梯度。
- 三种评分均未能预测产科并发症，提示需要个体化评估。
研究设计与样本
- 单中心回顾性队列研究，纳入2009至2023年在四级母胎中心分娩且孕周≥24+0周的407例心脏病女性妊娠。
- 主要结局为产后12个月内心脏并发症，次要结局为妊娠期或产后产科并发症。
主要发现
- 观察到的孕产妇心脏并发症率为4.18%（17例事件），无孕产妇死亡。
- CARPREG II加权平均预测风险为12.78%，mWHO为8.3%，ZAHARA为6.7%。
- O:E比值分别为CARPREG II 0.33、mWHO 0.50、ZAHARA 0.62，均显示风险被高估。
- mWHO、CARPREG II和ZAHARA的AUC分别为0.69（95% CI 0.55至0.80）、0.69（95% CI 0.53至0.83）和0.74（95% CI 0.61至0.85）。
- mWHO I至III级的产科并发症率分别为8.0%、7.0%和7.4%，三种模型对产科并发症的AUC均为0.5。
关键数值与推荐
- mWHO的AUC为0.69（95% CI 0.55至0.80），O:E比值为0.50。
- CARPREG II的AUC为0.69（95% CI 0.53至0.83），O:E比值为0.33。
- ZAHARA的AUC为0.74（95% CI 0.61至0.85），O:E比值为0.62。
临床怎么用
- 在当代专科实践中，使用这三种评分工具解释孕产妇心脏风险时需注意其可能高估绝对风险。
- 临床决策中应结合个体化评估，而非仅依赖上述评分的绝对风险预测值。
- 产科并发症的预测需要开发专门工具，现有心脏风险评分不适用于此目的。
局限性
- 单中心回顾性设计，样本量有限。
- 需要在更大规模和更多样化的人群中进一步验证。
以上解读依据论文摘要（全文未开放获取或许可不允许翻译转载）。
原文
Background Pregnancy in women with cardiac disease carries substantial maternal risk. The modified WHO classification, Cardiac Disease in Pregnancy Study II (CARPREG II) and Zwangerschap bij Aangeboren HARtAfwijkingen (ZAHARA; Pregnancy in Congenital Heart Disease) are the three principal risk stratification tools in this setting. External validation in contemporary practice is essential to assess its performance in specialist programmes. Methods Single-centre retrospective cohort study of all pregnancies in women with cardiac disease delivering ≥24+0 gestational weeks at a level IV maternal centre between 2009 and 2023. The primary outcome was maternal cardiac complication within 12 months postpartum; the secondary outcome was obstetric complication during pregnancy or the postpartum period. Model accuracy was assessed by comparing the weighted average predicted risk with the observed number of cardiac events, using each scoring system’s original published definitions. Additional performance measures included observed-to-expected (O:E) ratios and logistic-regression area under the curve (AUC). Results Among 85 473 deliveries, 407 pregnancies in 282 women were included. The observed maternal cardiac complication rate was 4.18% (17 events); no maternal deaths occurred. All three models overestimate risk: weighted average predicted rates were 12.78% (CARPREG II), 8.3% (mWHO) and 6.7% (ZAHARA), yielding O:E ratios of 0.33, 0.50 and 0.62, respectively. Discrimination was moderate across all scores (AUC 0.69 (95% CI 0.55 to 0.80), 0.69 (95% CI 0.53 to 0.83) and 0.74 (95% CI 0.61 to 0.85) for mWHO, CARPREG II and ZAHARA, respectively. Obstetric complication rates were similar across mWHO classes (8.0%, 7.0% and 7.4% for classes I–III). No score predicted obstetric complications (AUC 0.5 for all models). Conclusions Cardiac risk stratification scores might overestimate maternal cardiac risk in this contemporary specialist cohort, consistent with calibration drift, while preserving a clinically meaningful cardiac risk gradient. None captured obstetric risk. These findings highlight the role of individualised assessment. While our findings provide useful preliminary insight, further evaluation in larger and more diverse cohorts is needed to refine risk prediction.
引用
- Open Heart：Maternal cardiac risk stratification in contemporary practice: external validation of mWHO, CARPREG II and ZAHARA in a 14-year tertiary cohort
供执业医师工作参考，不替代临床判断；数值与分级以指南原文为准。