Management of COVID-19 cardiac complications during pregnancy requires a ‘pregnancy cardiac team’ to optimize patient care, says the American College of Cardiology (ACC) Women’s Cardiovascular Diseases Committee I am writing in a new report.
This multidisciplinary team includes providers familiar with high-risk pregnancies, obstetric anesthesia, cardiology, critical care, and neonatal care, depending on the nature of the complication, stage of pregnancy, and severity of disease can do. From the University of Illinois at Chicago and colleagues.
This group summarizes what is known about pregnancy-related COVID-19 cardiovascular complications in a “state of the art” review. publish online August 10 JACC: Advanced.
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Pregnant women are more likely to develop severe COVID-19 infection and may require treatment in an intensive care unit. mechanical ventilationand extracorporeal membrane oxygenation (ECMO), they note.
Pregnant women may suffer from myocardial injury, arrhythmias, and heart failurecompared with non-pregnant women of reproductive age.
Factors that increase the risk of cardiac complications during pregnancy include maternal age older than 35 years, high BMI, and pre-existing comorbidities such as chronic hypertension, diabetes and cardiovascular disease. . preeclampsiaracial/ethnic minorities, and unvaccinated status.
Regarding management considerations, Briller and colleagues say it is important to distinguish between pregnancy-specific complications such as pre-eclampsia. peripartum cardiomyopathyand spontaneous coronary artery dissection (SCAD) — from other COVID-19-related cardiac complications.
However, they note that current statements on COVID-19-related heart complications do not include pregnancy complications that can mimic COVID-19 complications.
One challenge is that some of the prothrombotic changes of pregnancy, such as complement activation, release of proinflammatory cytokines, antigen-antibody dysreactivity, prothrombotic phenomena, and endothelial vascular dysregulation, may contribute to immune-mediated severe disease. They say that it is similar to a type. Percentage of COVID-19 believed to cause infectious myocardial damage.
Pregnant women with severe COVID-19 infection or multiple risk factors (such as diabetes, hypertension, advanced age, smoking, obesity, and previous cardiovascular disease) should be assumed to be at highest risk of myocardial injury.
Although there are currently no standard recommendations for when to check for cardiac biomarkers, the writing group suggests considering it in pregnant women with moderate or severe COVID.
Chest discomfort thought to be of cardiac origin, whether acute or persistent, requires biomarker assessment. Levels that exceed his baseline by more than 20% should be further evaluated, they say.
In the setting of chest discomfort with abnormal biomarkers, the differential diagnosis includes demand ischemia, myocarditis, stress cardiomyopathyWhen acute coronary syndrome.
Overall, the group notes that the approach to diagnosis of suspected myocardial injury is similar to that in nonpregnant patients. Initial evaluation consists of history and physical examination findings, chest x-ray, electro-cardiogram (ECG), cardiac biomarkers, and frequently echocardiography.
Urgent angiography is ‘reasonable’ if ECG suggests ST elevation myocardial infarction, especially for classic symptoms. Ambiguous symptoms or ECG findings can prompt evaluation with focused or complete transthoracic echocardiography (TTE).
The presence of wall motion abnormalities helps guide the decision whether to proceed with coronary angiography, CT angiography (CTA), or drug therapy.
CTA is an option for stable patients or patients with differing findings to rule out acute coronary syndromes or to point to another diagnosis.
“Be careful” about heart disease
Heart failure can be especially difficult in the setting of pregnancy. Symptoms of heart failure can mimic those of a normal pregnancy, and the signs and symptoms of COVID-19 infection can further obscure the clinical picture.
“Thus, attention should be paid to the assessment of heart failure and cardiomyopathy when managing pregnant women infected with COVID-19, especially those who are moderately to severely ill or who have evidence of myocardial damage,” said the group. is advising.
They say that COVID-related cardiomyopathy should be distinguished from peripartum cardiomyopathy (PPCM) because of its implications for long-term follow-up and counseling for future pregnancy risk.
The timing of heart failure onset helps distinguish between PPCM and pregnancy-related COVID-related cardiomyopathy.
Heart failure associated with COVID-19 infection can occur during pregnancy, but PPCM usually develops late in pregnancy or several months after delivery.
However, the two conditions can be difficult to distinguish between patients infected with COVID late in pregnancy or early postpartum and those with common risk factors for both conditions.
In summary, it is important for clinicians to know that most cardiac complications described outside of pregnancy, including arrhythmias, myocardial injury, thromboembolic complications, and long-distance symptoms, have also been reported in pregnant women. the authors say.Additional concerns include increased risk premature labor Birth and development of pre-eclampsia.
The group encourages cardiologists to be “vigilant” when evaluating cardiac complications in women with COVID-19.
We should also encourage COVID-19 vaccination of pregnant women as recommended by the Centers for Disease Control and Prevention (CDC), the American College of Obstetricians and Gynecologists, and the College of Maternal-Fetal Medicine guidelines.
There was no special funding for this study. Briller is a member of the steering committee and a site investigator for the REBIRTH study.
JACC: AdvancedPublished online on August 10, 2022. Overview
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