By Mollie Frost
During a Friday session at Internal Medicine Meeting 2021: Virtual Experience, Katie Hawthorne, MD, offered tips on recognizing and managing acute cardiac diseases affecting women, including spontaneous coronary artery dissection (SCAD) and peripartum cardiomyopathy.
SCAD
SCAD is a noniatrogenic dissection or intraluminal hematoma of the coronary artery, which results in luminal narrowing and reduction of blood flow, explained Dr. Hawthorne, who is a cardiologist at Lankenau Medical Center in Wynnewood, Pa. Most patients who come in with a SCAD (81% to 95%) are female. "The mean age is young—44 to 53—so certainly something to keep on the differential for that younger patient," she said.
Female sex hormones appear to be associated with SCAD, as evidenced by a case Dr. Hawthorne presented. "Our patient who I presented was on oral contraceptives, [and] we sometimes see this in the setting of hormone replacement therapy or around pregnancy," she said. Pregnancy-associated SCAD can also occur postpartum, and it is the most common cause of myocardial infarction in pregnancy, she noted.
Fibromuscular dysplasia (FMD) is also commonly associated with SCAD. "Women who have a spontaneous dissection should be scanned from their head to their pelvis looking for other arterial involvement for FMD," Dr. Hawthorne said. SCAD is also associated with connective tissue disorders, genetic predispositions, and extreme physical exertion or emotional stress, she added.
For inpatient care, Dr. Hawthorne recommended the 2014 American Heart Association/American College of Cardiology guideline for management of non-ST-elevation acute coronary syndrome. "If the patient is stable without significant obstruction, we often will elect for medical therapy and not intervene in these vessels that are abnormal and fragile," she said.
Perhaps the most important piece to keep in mind is that these patients should be monitored in the hospital for a longer period of time than those with a myocardial infarction typically are nowadays, Dr. Hawthorne said. "There is a risk of recurrence in the three to five [-day] range, so inpatient management for up to five days is recommended." After discharge, patients should be referred to cardiac rehab.
Peripartum cardiomyopathy
Another issue to watch for in women who are or recently were pregnant is peripartum cardiomyopathy. "The rates of maternal mortality are high in the United States compared to other developed countries, and peripartum cardiomyopathy is a big one, so it's really a no-miss diagnosis for us," said Dr. Hawthorne. The incidence in the U.S. is about one in 1,000 to 4,000 live births, and it is two to three times higher in Black women, she said. Risk factors include age older than 30 years, hypertensive disorders of pregnancy, and multiple pregnancies.
"The clinical presentation is just like heart failure: dyspnea, orthopnea, [paroxysmal nocturnal dyspnea], edema," Dr. Hawthorne said. "You certainly can see shock, [venous thromboembolism], stroke as a result of thrombus … but unfortunately the diagnosis is often missed or delayed as symptoms can be mistaken for normal pregnancy."
Treatment includes mechanical support if needed and guideline-directed medical therapy. "You do have to be careful, of course, with certain drugs during pregnancy like ACE [angiotensin-converting enzyme inhibitors], ARBs [angiotensin receptor blockers], ARNIs [angiotensin receptor neprilysin inhibitors], which are contraindicated in pregnancy, but postpartum you certainly can use certain ACE inhibitors and continue breastfeeding. … You can use mineralocorticoid receptor antagonists postpartum; you can't use them during pregnancy," Dr. Hawthorne said.
Beta-blockers are considered safe in pregnancy or while breastfeeding, especially beta-1 selectives, she added. Dr. Hawthorne also advised considering anticoagulation for patients with severely reduced ejection fraction because they are hypercoagulable and at risk for thrombus.
The estimated risk of death after peripartum cardiomyopathy is 10% in two years, she said. "When we're thinking about young moms, that's obviously way too high," said Dr. Hawthorne. On the plus side, the likelihood of myocardial recovery is also high and often occurs within six months postpartum.
However, women who present with severely reduced left ventricular ejection fraction (25% or less) at baseline or who have persistent left ventricular dysfunction should not consider a repeat pregnancy, she said. "But of course, this is a multidisciplinary discussion that should be had down the road." ■