Myocardial Effects Seen in Some Pregnant Women With Severe COVID-19

By Marilynn Larkin

October 28, 2020

NEW YORK (Reuters Health) - Cardiac biomarkers are elevated in some pregnant women with COVID-19, but the significance is unclear, researchers say.

"Right now, we know that many biomarkers may be abnormal in patients with COVID-19, including inflammatory, thrombotic, and cardiac markers," Dr. Sarah Pachtman Shetty of Northwell Health Lenox Hill Hospital in New York City told Reuters Health by email.

It is difficult to say whether clinicians should be measuring cardiac biomarkers "without knowing the long-term clinical impact of abnormal cardiac markers on the health of these patients," she said. "Having this information may guide follow-up - for instance, it could help with the decision for future testing or cardiac imaging."

That said, she noted, "When myocardial injury is suspected in a pregnant person with COVID-19 infection because of symptoms or other findings such as EKG changes, biomarkers such as B-type natriuretic peptide and serum cardiac troponins are indicated, just as they are in non-pregnant patients, since the results may influence clinical care."

Dr. Pachtman Shetty and colleagues analyzed medical records of all pregnant and immediately postpartum women hospitalized for COVID-19 at seven hospitals in the Northwell Health system in March and April, focusing on the 31 women who met National Institutes of Health criteria for severe or critical illness (mean age, 33).

The primary outcomes were elevated cardiac troponins, elevated brain natriuretic peptide (BNP), bradycardia (<60 bpm), and maternal heart rate nadir.

As reported in the American Journal of Obstetrics and Gynecology, 20 of the women (65%) had cardiac biomarkers measured. None had pre-existing cardiovascular disease or hypertension.

Cardiac troponins and BNP were elevated in 22% (4/18) and 30% (3/10) of women whose biomarkers were measured. Four had transthoracic echocardiograms done, with normal results.

Two women in the cohort died; both had elevated cardiac troponins and one also had an elevated BNP.

The nadir heart rate ranged from 30-92 beats per minute, and bradycardia occurred in one-third of patients (10/31). Half of those with elevated troponin and three-fourths of those with elevated BNP had an episode of bradycardia while hospitalized.

The retrospective study had a number of limitations, according to the authors, including small sample size, heterogeneity in laboratory testing and imaging and selection bias.

Dr. Pachtman said, "So much is unknown about the optimal management of patients with COVID-19-associated myocardial injury, and additional factors come in to play when the patient is pregnant. A team approach with members with expertise in their fields is imperative for the best outcome."

Dr. Diana Wolfe, Associate Maternal Fetal Medicine Fellowship Director at Albert Einstein College of Medicine/Montefiore Medical Center in New York City, commented in an email to Reuters Health, "Current recommendations from the American Heart Association include longitudinal follow-up with a cardiologist for women who have had complicated pregnancies. These findings suggest the same for pregnant women infected with COVID 19 manifesting severe symptoms."

"ACOG practice bulletin 212 on pregnancy and heart disease (https://bit.ly/2TI5XnL) includes a cardiovascular screening toolkit suggested for all pregnant patients," she noted. "The majority of the cohort described in this study would screen positive (based on their vital signs upon presentation) and require a BNP followed by further cardiac evaluation with a cardio-obstetric team."

"Currently, there is no protocol for how to manage these women postpartum," she added. "However, I would recommend at minimum close monitoring for the first six months."

SOURCE: https://bit.ly/2TthEhE American Journal of Obstetrics and Gynecology, online October 9, 2020.

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