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Clinical Context

COVID-19 often has cardiovascular (CV) complications, including microvascular and macrovascular thrombotic complications of arterial and venous thromboembolism, myocardial injury, or inflammation causing myocardial infarction (MI), heart failure (HF), and arrhythmias. Evidence suggests greater risk for adverse COVID-19 outcomes in pregnant vs nonpregnant women of reproductive age, including intensive care unit (ICU) admission, mechanical ventilation, and extracorporeal membrane oxygenation (ECMO).

Case series of pregnancy-associated COVID-19 have shown MI, ventricular dysfunction, arrhythmias, thrombotic complications, higher preeclampsia risk, and “long haul” symptoms. As prevalence of vaccinated women is lower than in other population groups, the potential for CV complications may remain high during pregnancy.

Study Synopsis and Perspective

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 (CVD) in Women Committee wrote in a new report.

This interprofessional team can include clinicians 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, suggested Joan E. Briller, MD, from the University of Illinois, Chicago, and colleagues.

The group summarized what is known about pregnancy-associated COVID-19 CV complications in a "state-of-the-art" review, published in the August issue of JACC: Advances.

Pregnant women can be more apt to develop severe COVID-19 and require ICU care, mechanical ventilation, and ECMO, they pointed 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 (BMI); preexisting comorbidities, such as chronic hypertension, diabetes, CVD, and preeclampsia; racial/ethnic minority; and unvaccinated status.

In terms of management considerations, Briller and colleagues said it is important to distinguish unique complications of pregnancy -- such as preeclampsia, 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 pointed out.

One challenge, they said, 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 or with multiple risk factors -- such as diabetes, hypertension, older age, smoking, obesity, and previous CVD -- 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 said.

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

Overall, the group noted 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 (STEMI), 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, computed tomography angiography (CTA), or medical therapy.

Computed tomography angiography (CTA) is an option for stable patients or patients with divergent findings to rule out ACS or point to an alternative diagnosis.

Heart failure can be particularly challenging in the setting of pregnancy. Symptoms of HF can mimic those of normal pregnancy, and the signs and symptoms of COVID-19 can further obscure the clinical picture. Members of the interprofessional team play a vital role in evaluation, diagnosis, and management of these patients.

"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 [HF] and cardiomyopathy," the group advised.

They said 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 HF presentation can help distinguish PPCM from pregnancy-associated COVID-related cardiomyopathy.

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

Still, the 2 conditions can be challenging to differentiate in patients with COVID-19 during the third trimester or the early postpartum period and among patients with risk factors common to both conditions.

Summing up, the authors said it is important for physicians to know that most cardiac complications described outside of pregnancy, such as arrhythmias, myocardial injury, thromboembolic complications, and long-haul symptoms, women also report during pregnancy. Additional concerns include increased risk for preterm labor and delivery and development of preeclampsia.

The group encouraged cardiologists and members of the interprofessional team to be "vigilant" in assessing women with COVID-19 for cardiac complications.

Members of the care team should also encourage and provide education on COVID-19 vaccination of pregnant women, as recommended in guidelines from the 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 Adv. 2022;1:100057.^[1]

Clinical Implications

• Pregnant women at highest risk for myocardial injury are those individuals with severe COVID-19 or with multiple risk factors.
• Pregnancy complications that may mimic and must be distinguished from other COVID-19 complications include PPCM, SCAD, and preeclampsia.
• Implications for the Healthcare Team: Diagnosis and management of cardiac complications of COVID-19 during pregnancy requires an interprofessional healthcare team to improve patient outcomes.

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