Kathryn J. Lindley

Acute Myocardial Infarction in Women: A Scientific Statement From the American Heart Association

Cardiovascular disease is the leading cause of mortality in American women. Since 1984, the annual cardiovascular disease mortality rate has remained greater for women than men; however, over the last decade, there have been marked reductions in cardiovascular disease mortality in women. The dramatic decline in mortality rates for women is attributed partly to an increase in awareness, a greater focus on women and cardiovascular disease risk, and the increased application of evidence-based treatments for established coronary heart disease. This is the first scientific statement from the American Heart Association on acute myocardial infarction in women. Sex-specific differences exist in the presentation, pathophysiological mechanisms, and outcomes in patients with acute myocardial infarction. This statement provides a comprehensive review of the current evidence of the clinical presentation, pathophysiology, treatment, and outcomes of women with acute myocardial infarction.

Contraceptive Use and Unintended Pregnancy in Women With Congenital Heart Disease.

OBJECTIVE: To identify patterns of contraceptive use and pregnancy in an academic adult congenital cardiology practice. METHODS: In this cross-sectional study, from October 2013 through March 2014, 100 women with congenital heart disease aged 18–45 years were recruited from an academic congenital heart disease clinic and administered a survey regarding pregnancy history, contraception use, and understanding of pregnancy-related and contraceptive-related risk. The primary outcome was current use of long-acting reversible contraception, including intrauterine devices or subdermal implants. RESULTS: Of 83 sexually active women, 63 (75.9%, 95% confidence interval [CI] 65.3–85.1) reported currently using any contraceptive method, including 30 of 83 (36.1%, 95% CI 25.9–47.4) using tier I methods (typical-use failure rates of less than 1% per year) and 20 of 83 (24.1%, 95% CI 15.4–34.7) using tier II methods (typical-use failure rates of 6–12% per year). Nine of 83 (10.8%, 95% CI 5.1–19.6) reported currently using long-acting reversible contraception. Sixty-four of 141 total pregnancies (45.4%, 95% CI 31.9–58.9) were self-reported by participants as “unexpected” rather than “planned.” Only one (1.6%, 95% CI 0–4.6) of the 64 unintended pregnancies occurred when the woman was using a tier I method of contraception at the time of conception. CONCLUSION: Most women with congenital heart disease of childbearing age are sexually active. The high incidence of unintended pregnancy in this group may be related to underuse of highly effective methods of contraception. Specific counseling on tier I methods may reduce unintended pregnancies in women with congenital heart disease. LEVEL OF EVIDENCE: III

Contraception and Pregnancy Planning in Women With Congenital Heart Disease.

Opinion statementThe cardiovascular risk of pregnancy among women with congenital heart disease is heterogeneous, ranging from negligible to prohibitively high. Nonetheless, many of these patients do not report being counseled about the potential risks, and the incidence of unintended pregnancy is high. These women should be counseled on safe and effective contraceptive options. Long-acting reversible contraceptives, including the intrauterine devices and etonogestrel implant, are highly effective and safe for all cardiac patients. These are good options for pregnancy planning for women at elevated risk of cardiovascular complications during pregnancy, who are taking potentially teratogenic medications, or who have contraindications to estrogen-containing methods. Pregnancy management begins with pre-conceptual risk stratification and counseling regarding individual cardiovascular and fetal risks. As significant lapse in care is common at the time of transition to adult congenital cardiology care, these discussions ideally begin in pediatric clinics and continue upon transfer of care to adult congenital cardiology clinics.

Adult Congenital Heart Disease in Pregnancy.

&NA; With the success of modern surgical techniques for congenital heart disease, the population of women of childbearing age with congenital heart disease is growing. Because of the significant hemodynamic load of pregnancy, labor, and delivery, women with congenital heart disease require preconceptual risk assessment and expert multidisciplinary care throughout pregnancy. The aim of this review is to discuss the management of cardiovascular, obstetric, and fetal care issues that are commonly encountered during pregnancy in women with congenital heart disease. Target Audience Obstetricians gynecologists, family physicians Learning Objectives After completing this activity, the learner will be better able to discuss the importance of preconceptual risk assessment of pregnancy risk for women with adult congenital heart disease; identify disease-specific complications associated with pregnancy in women with adult congenital heart disease; identify common fetal risks associated with pregnancy in women with adult congenital heart disease; and explain the importance of delivery planning in women with adult congenital heart disease.

Impact of Preeclampsia on Clinical and Functional Outcomes in Women With Peripartum CardiomyopathyCLINICAL PERSPECTIVE

Background— Preeclampsia is a risk factor for the development of peripartum cardiomyopathy (PPCM), but it is unknown whether preeclampsia impacts clinical or left ventricular (LV) functional outcomes. This study sought to assess clinical and functional outcomes in women with PPCM complicated by preeclampsia. Methods and Results— This retrospective cohort study included women diagnosed with PPCM delivering at Barnes-Jewish Hospital between 2004 to 2014. The primary outcome was one-year event-free survival rate for the combined end point of death and hospital readmission. The secondary outcome was recovery of LV ejection fraction. Seventeen of 39 women (44%) with PPCM had preeclampsia. The groups had similar mean LV ejection fraction at diagnosis (29.6 with versus 27.3 without preeclampsia; P=0.5). Women with preeclampsia had smaller mean LV end-diastolic diameters (5.2 versus 6.0 cm; P=0.001), greater relative wall thickness (0.41 versus 0.35 mm Hg; P=0.009), and lower incidence of eccentric remodeling (12% versus 48%; P=0.03). Clinical follow-up was available for 32 women; 5 died of cardiovascular complications within 1 year of diagnosis (4/15 with versus 1/17 without preeclampsia; P=0.16). In time to event analysis, patients with preeclampsia had worse event-free survival during 1-year follow-up (P=0.047). Echocardiographic follow-up was available in 10 survivors with and 16 without preeclampsia. LV ejection fraction recovered in 80% of survivors with versus 25% without preeclampsia (P=0.014). Conclusions— PPCM with concomitant preeclampsia is associated with increased morbidity and mortality and different patterns of LV remodeling and recovery of LV function when compared with patients with PPCM that is not complicated by preeclampsia.

Impact of pregnancy on autograft dilatation and aortic valve function following the Ross procedure

OBJECTIVE The effects of pregnancy on autograft dilatation and neoaortic valve function in patients with a Ross procedure have not been studied. We sought to evaluate the effect of pregnancy on autograft dilatation and valve function in these patients with the goal of determining whether pregnancy is safe after the Ross procedure. DESIGN A retrospective chart review of female patients who underwent a Ross procedure was conducted. PATIENTS Medical records for 51 patients were reviewed. Among the 33 patients who met inclusion criteria, 11 became pregnant after surgery and 22 did not. OUTCOME MEASURES Echocardiographic reports were used to record aortic root diameter and aortic insufficiency before, during, and after pregnancy. Patients charts were reviewed for reinterventions and complications. Primary endpoints included reinterventions, aortic root dilation of ≥5 cm, aortic insufficiency degree ≥ moderate, and death. RESULTS There were 18 pregnancies carried beyond 20 weeks in 11 patients. There was no significant difference in aortic root diameter between nulliparous patients and parous patients prior to their first pregnancy (3.53 ± 0.44 vs 3.57 ± 0.69 cm, P = .74). There was no significant change in aortic root diameter after first pregnancy (3.7 ± 0.4 cm, P = .056) although there was significant dilatation after the second (4.3 ± 0.7 cm, P = .009) and third (4.5 ± 0.7 cm, P = .009) pregnancies. Freedom from combined endpoints was significantly higher for patients in the pregnancy group than those in the nonpregnancy group (P = .002). CONCLUSIONS Pregnancy was not associated with significantly increased adverse events in patients following the Ross procedure. Special care should be taken after the first pregnancy, as multiparity may lead to increased neoaortic dilatation.

Pregnancy after Aortic Root Replacement in Marfan's Syndrome: A Case Series and Review of the Literature

Objectives  We sought to characterize pregnancy-related aortic complications in women with Marfans syndrome who had prior aortic root replacement. Study Design  This is a retrospective case series study and literature review of women with Marfans syndrome with pregnancy after aortic root replacement. We surveyed women with Marfans syndrome who had successful pregnancy after aortic root replacement using the Marfan Foundation Website and from two large tertiary care Marfans clinics. Clinical data, counseling information, and details of pregnancy-related aortic complications were compiled. A literature review was performed assessing aortic outcomes in women with Marfans syndrome with pregnancy after aortic surgery. Results  Fourteen women with 20 pregnancies were identified. Two women had three pregnancies following root replacement for aortic dissection. There were no aortic dissections during the 20 pregnancies. In contrast, aortic dissection was frequently reported in the literature. Conclusions  Women with Marfans syndrome who become pregnant following aortic root replacement remain at risk for distal aortic dissection related to pregnancy. The exact risk is difficult to quantify but is not zero and women should be counseled accordingly.

Antibody-mediated rejection of the heart in the setting of autoimmune demyelinating polyneuropathy: a case report and review of the literature.

Background. Antibody-mediated rejection (AMR) is caused by the production of donor-specific antibodies (DSA) which lead to allograft injury in part via complement activation. The inflammatory demyelinating polyneuropathies (IDP) are inflammatory disorders of the nervous system, involving both cellular and humoral immune mechanisms directed against myelin. Case Report. A 58-year-old man five years after heart transplant presented with progressive dyspnea, imbalance, dysphagia, and weakness. Nerve conduction studies and electromyogram were consistent with IDP. Plasmapheresis and high-dose steroids resulted in improvement in neurologic symptoms. Within two weeks, he was readmitted with anasarca and acute renal failure, requiring intravenous furosemide and inotropic support. Echocardiogram and right heart catheterization revealed reduced cardiac function and elevated filling pressures. DSA was positive against HLA DR53, and endomyocardial biopsy revealed grade 1R chronic inflammation, with strong capillary endothelial immunostaining for C4d. Plasmapheresis and intravenous immunoglobulin (IVIG) were initiated. His anasarca and renal failure subsequently resolved, echocardiogram showed improved function off inotropes, and anti-DR53 MFI was reduced by 57%. Conclusions. This is an example of a single immune-mediated process causing concurrent IDP and AMR. The improvement in cardiac function and neurologic symptoms with plasmapheresis, IVIG, and high-dose steroids argues for a unifying antibody-mediated mechanism.