Pregnancy-Related CV Risks: Urgent Need for Tailored Care

In posters presented on day 1 of the 2024 European Society of Cardiology Congress, international research was delivered on pregnant and postpartum women in 3 important areas of specialized care for cardiovascular diseases: care guidelines, inherited cardiomyopathies, and short-term disease outcomes. These patients are considered high risk and they require specialized care from a multidisciplinary team because of the physiological changes introduced during pregnancy that can not only impact current cardiovascular disease states but bring on potential new disease-related complications.

Care Guidelines in Pregnant/Postpartum Women¹

The mortality rate from cardiovascular disease among pregnant women in the US more than doubled in the 3-decade span between 1987 and 2019, according to research from from Scripps Clinic in La Jolla, California—jumping from approximately 7.2 deaths to 17.6 deaths among 100,000 live births. And these outcomes are not equal among racial and ethnic groups. Using data from 13 randomized controlled trials in 47 countries—46% from Europe and 54% from the US—these authors wanted to evaluate current major cardiology guidelines and highlight where care gaps exist to suggest how to improve evidence-based care for women during their pregnancy and postpartum periods.

Close to 21,000 women with a mean age of 31 years were included in this analysis, and most participants (76.7%) were non-Hispanic White patients; only 4 of the 13 trials investigated outcomes among Black patients; 3, Asian patients; and 1, Hispanic patients. Overall, less than half of the trials (46%) even reported data on race or ethnicity. Most of these trials had investigated hypertension (n = 8); just 2 reported on venous thromboembolism, and 1, heart failure.

Comparing guidelines from ESC, the American Heart Association, and the American College of Cardiology against cardiovascular pregnancy-related deaths, the investigators found that most deaths occurred among Black patients across cardiac and coronary conditions, embolic/thrombotic episodes, cardiomyopathy, hypertensive disorders of pregnancy, and cerebrovascular accidents—in stark contrast to these patients’ representation in trials of these conditions. Further, 21.9% of cardiac and coronary conditions were seen in Asian patients and 15.9% in Black patients compared with 10.7% among White patients. Black patients, compared with White patients, represented more cases of cardiovascular pregnancy-related deaths for embolic/thrombotic episodes (11.9% vs 7.4%), cardiomyopathy (13.9% vs 7.2%), hypertensive disorders of pregnancy (9.9% vs 4.8%), and cerebrovascular accidents (3.3% vs 2.6%).

There is a severe lack of evidence-based recommendations for managing these conditions during the pregnancy and postpartum periods among minority patients, the authors wrote, and there need to be more randomized controlled trials that evaluate the conditions among these patients so that practice guidelines can effectively advocate for them.

These studies examined outcomes among pregnant and pospartum women with preexisting or new-onset CVD, emphasizing that these patients require specialized and more research is needed to improve their outcomes. | Image Credit: tolikoffphotography - stock.adobe.com

Inherited Cardiomyopathies in Pregnant/Postpartum Women²

In this retrospective analysis, the authors evaluated care and outcomes among women with modified World Health Organization (mWHO) class I or II, II/III, III, and IV disease, focusing on 4 inherited cardiomyopathies: hypertrophic cardiomyopathy (HCM), dilated cardiomyopathy (DCM), arrhythmogenic right ventricular cardiomyopathy (ARVC), and peripartum cardiomyopathy (PPCM). This analysis covered 2016 through 2023 for all pregnant women with cardiomyopathy who received care at St. George’s University Hospital in London (N = 86).

Among these women, there were 81 live births, with most occurring among patients with class III disease (42%), followed by class II/III disease (27.2%), class I or II disease (21%), and class IV disease (9.8%). There were 5 miscarriages, all within the first trimester, and all of the women survived their pregnancies and postpartum periods of care.

HCM was most common in women with class II/III disease (63.6%) compared with class IV (62.5%), class III (61.8%), and class I or II (41.2%) disease. DCM was seen most among women with class I or II disease (41.2%) vs class II/III (36.4%), class III (38.2%), and class 4 (25%) disease. ARVC was only seen in women with class I or II and IV disease, and was more common in patients with class I disease (17.6% vs 12.5%). PPCM was only seen in women with class III disease (61.8%).

Overall, there were more cases of pregnancy-related events in the women with class II/III disease vs class I or II disease (34.6% vs 1.2%). The most common events were supraventricular tachycardia (13.6%), gestational diabetes (11.1%), left ventricular ejection fraction impairment (4.9%), preeclampsia (3.7%), and ventricular tachycardia (1.2%) in the women with higher-class disease compared with just 1 case of gestational diabetes in a woman with lower-class disease.

Of the 2 types of delivery—vaginal or caesarean—vaginal delivery was significantly more common among the women with class I or II and II/III disease (82.4% and 81.8%, respectively) vs caesarean delivery (17.6% and 18.2%), and caesarean delivery, much more common in those with class IV disease (62.5% vs 37.5%). There was 1 case of retroperitoneal hematoma in a patient with class II/III disease following a caesarean delivery.

With these results, the authors highlight the higher risks of adverse events that pregnant patients with cardiomyopathy could experience and they recommend coupling careful monitoring and specialized care with a comprehensive risk assessment to optimize outcomes for both mother and child.

Short-Term Outcomes in Pregnant/Postpartum Women³

Increases in their plasma volume and cardiac output and hypercoagulability are some of the cardiovascular changes that pregnant women experience, and they import greater risks of complications among pregnant patients with preexisting cardiovascular disease. Because of these risks, ESC guidelines recommend specialized care for these patients. Retrospective and prospective real-world data from November 2022 through August 2024 from the Pregnancy Heart Team at University Hospital Heidelberg, in Germany, were used for this analysis; women with preexisting cardiovascular disease (59.3%) and those with pregnancy-related new-onset cardiovascular disease (40.7%) were included (N = 54). Half have mWHO class II/III disease, and 17 of the women are pregnant or trying to get pregnant.

The mean (SD) patient age was 33 (6) years, and the mean duration of mWHO cardiovascular disease was 2.2 (1) years. Smoking history was the most common cardiovascular risk factor (20.3%), followed by hypertension (16.7%), family history of cardiovascular disease (14.8%), hypercholesterolemia (11.1%), diabetes (9.3%), and obesity (5.5%). Of the 70.4% with a history of cardiovascular disease, only 37.5% were on any cardiac medication and 25.9% had a history of complicated pregnancy.

Cardiomyopathies, congenital heart defects, and valvular heart disease were more common in the women with preexisting cardiovascular disease, while arrhythmias, ischemic heart disease, and hypertension were more common in the women who developed cardiovascular disease during pregnancy (18.4%). There were 14 premature births, the most common fetal complication, and the most common maternal complications were heart failure in 6 patients and gestational diabetes in 5 patients. Twelve percent of the women also developed preterm premature membrane rupture, and there were reports of macrosomia (10.2%), which is when the fetus is larger than average and can affect its heart rate,⁴ and intrauterine growth retardation (5.1%)

Preliminary data show that mean left ventricular ejection fraction was stable for the women who were pregnant and trended lower post delivery, and that the cardiac biomarkers of high-sensitivity troponin T and N-terminal pro b-type natriuretic peptide usually increased in the third trimester and postpartum periods.

The authors highlight how these data show the significant rate of adverse pregnancy outcomes in women with preexisting cardiovascular disease, and that understanding cardiac complications during pregnancy and the postpartum periods could benefit from future research. Standard parameters of cardiac measures do not apply, especially in those with preexisting cardiovascular disease.

References

1. Ekpo E, Elmore J, Uddin P. Unlocking equity: assessing for gaps in cardiovascular guidelines for pregnant women. Presented at: ESC Congress; August 30-September 2, 2024; London England.

2. Sola-García E, García-García AM, Casian M, et al. Pregnancy and inherited cardiomyopathies: insights from specialized care. Presented at: ESC Congress; August 30-September 2, 2024; London England.

3. Siry D, Hoerbrand I, Haney AC, Frey N, Ehlermann P, Beckendorf J. Preliminary data on short-term outcomes within the cardio-obstetrics registry of Heidelberg. Presented at: ESC Congress; August 30-September 2, 2024; London England.

4. Fetal macrosomia. Cleveland Clinic. Updated May 13, 2022. Accessed August 31, 2024. https://my.clevelandclinic.org/health/diseases/17795-fetal-macrosomia