Higher Cardiac COVID Risks in Pregnancy Require Team Care

Megan Brooks

August 15, 2022

Management of the cardiac complications of COVID-19 during pregnancy requires a "pregnancy heart team" to optimize patient care, the American College of Cardiology (ACC) Cardiovascular Disease in Women committee writes in a new report.

This multidisciplinary team can include providers comfortable with high-risk pregnancy, obstetric anesthesia, cardiology, critical care, and neonatal care, depending on the nature of the complication, stage of pregnancy, and severity of disease, suggest Joan E. Briller, MD, from the University of Illinois, Chicago, and colleagues.

The group summarizes what is known about pregnancy-associated COVID-19 cardiovascular complications in a "state-of-the-art" review, published online August 10 in JACC: Advances.

Challenging Group

Pregnant women can be more apt to develop severe COVID-19 infection and require intensive care unit care, mechanical ventilation, and extracorporeal membrane oxygenation (ECMO), they point out.

Pregnant women are also at elevated risk for the cardiac complications of COVID-19, including myocardial injury, arrhythmias, and heart failure, compared with nonpregnant women of reproductive age.

Factors associated with a higher risk for cardiac complications in pregnancy include maternal age over 35 years, higher body mass index, and pre-existing comorbidities, such as chronic hypertension, diabetes, cardiovascular disease, and pre-eclampsia, racial/ethnic minority, and unvaccinated status.

In terms of management considerations, Briller and colleagues say it's important to distinguish unique complications of pregnancy — such as pre-eclampsia, peripartum cardiomyopathy, and spontaneous coronary dissection (SCAD) — from other COVID-19-associated cardiac complications.

However, current statements addressing COVID-19-associated cardiac complications do not include pregnancy complications that can mimic COVID-19 complications, they point out.

One challenge, they say, is that some of the prothrombotic changes of pregnancy, such as complement activation, release of proinflammatory cytokines, antigen-antibody abnormal responses, prothrombotic phenomena, and endothelial-vascular dysregulation, are similar to the immune-mediated severe forms of COVID-19 thought to be responsible for myocardial injury with infection.

Pregnant women with severe COVID-19 infection or with multiple risk factors — such as diabetes, hypertension, older age, smoking, obesity, and previous cardiovascular disease — should be assumed to be at the highest risk for myocardial injury.

Although there currently is no standard recommendation for when cardiac biomarkers should be checked, 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, warrants evaluation with biomarkers. Levels more than 20% above baseline warrant further evaluation, they say.

In the setting of chest discomfort with abnormal biomarkers, differential diagnosis includes demand ischemia, myocarditis, stress cardiomyopathy, and acute coronary syndromes.

Overall, the group notes that approaches to the diagnosis of suspected myocardial injury are similar to those in nonpregnant patients. Initial assessment is based on history and physical exam findings, chest x-ray, electrocardiogram (ECG), cardiac biomarkers, and frequently echocardiography.

Urgent angiography is "reasonable" when the ECG suggests ST-segment elevation myocardial infarction, especially with classic symptoms. Equivocal symptoms or ECG findings can prompt evaluation with a focused or full transthoracic echocardiography (TTE).

The presence of wall motion abnormalities will help guide the decision to proceed to coronary angiography, CT angiography (CTA), or medical therapy.

CTA is an option for stable patients or patients with divergent findings to rule out acute coronary syndromes or point to an alternative diagnosis.

"Be Vigilant" for Heart Problems

Heart failure can be particularly challenging in the setting of pregnancy. Symptoms of heart failure can mimic those of normal pregnancy, and the signs and symptoms of COVID-19 infection can further obscure the clinical picture.

"Therefore, when managing pregnant women with COVID-19, particularly those with moderate-severe illness or those with evidence of myocardial injury, care should be taken to evaluate for heart failure and cardiomyopathy," the group advises.

They say COVID-related cardiomyopathy needs to be differentiated from peripartum cardiomyopathy (PPCM), owing to implications for long-term follow-up and counseling about the risks with future pregnancies.

The timing of heart failure presentation can help distinguish PPCM from pregnancy-associated COVID-related cardiomyopathy.

Heart failure related to COVID-19 infection can occur throughout pregnancy, whereas PPCM usually presents toward the end of pregnancy or in the months after delivery.

However, the two conditions can be challenging to differentiate in patients infected with COVID during the third trimester or the early postpartum period and among patients with risk factors common to both conditions.

Summing up, the authors say it's important for clinicians to know that most cardiac complications described outside of pregnancy, such as arrhythmias, myocardial injury, thromboembolic complications, and long-haul symptoms, are also reported in women during pregnancy. Additional concerns include increased risk for preterm labor and delivery and development of pre-eclampsia.

The group encourages cardiologists to be "vigilant" in assessing women with COVID-19 for cardiac complications.

They should also encourage COVID-19 vaccination of pregnant women, as recommended in guidelines from the US Centers for Disease Control and Prevention (CDC), American College of Obstetrics and Gynecology, and the Society of Maternal Fetal Medicine.

This research had no specific funding. Briller is on the steering committee and a site investigator for the REBIRTH trial.

JACC: Advances. Published online August 10, 2022. Abstract

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