Friday, March 31, 2023
Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™
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This activity is intended for obstetricians/gynecologists/women’s health physicians, cardiologists, diabetologists/endocrinologists, family medicine/primary care physicians, internists, critical care physicians, nurses, physician assistants, and other members of the healthcare team for pregnant women with ischemic heart disease (IHD).
The goal of this activity is for learners to be better able to describe adverse pregnancy outcomes of women with IHD compared with women with a cardiac diagnosis categorized by the modified World Health Organization (mWHO) classification and women without a cardiac diagnosis, according to a retrospective study using the 2015 to 2018 Nationwide Readmissions Database.
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CME / ABIM MOC / CE Released: 1/27/2023
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In the United States, leading causes of maternal death include cardiac diseases, with cardiac disease and cardiomyopathy accounting for more than 26%. With increasing maternal age in pregnancy and increases in obesity, hypertension, and other comorbidities, cardiovascular (CV) risk factors, such as preexisting ischemic heart disease (IHD), are also likely to increase among pregnant women.
A recent retrospective analysis and systematic review by Denoble and colleagues suggested that women entering pregnancy with preexisting IHD had an approximately 5% to 10% risk for ischemic CV complications. More comprehensive studies of outcomes in this population are lacking.
Women with preexisting IHD without another cardiac diagnosis have a higher risk for severe maternal morbidity and mortality than women with no cardiac disease, a new study suggests.
After adjustment for other comorbidities, however, the risk associated with isolated preexisting IHD without additional evidence of cardiomyopathy was relatively similar to that of other low-risk cardiac diseases.
"These are reassuring findings," lead author of the study, Anna E. Denoble, MD, Yale University School of Medicine, New Haven, Connecticut, told theheart.org | Medscape Cardiology.
"The risk is not zero. Women with preexisting [IHD] are at a small increased risk compared to women without preexisting cardiac disease. But with good control of [CV] risk factors, these women have a good chance of a positive outcome," she added.
The study was published in December in JACC: Advances.
"To our knowledge, this study provides the largest analysis to date examining the risk of severe morbidity and mortality among pregnant people with preexisting [IHD]," the authors noted.
Denoble, a maternal and fetal medicine specialist, explained that in recent years, there has been an increase in the number of patients with preexisting IHD who are considering pregnancy or who are pregnant when they present, but there is little information on outcomes for these patients.
The diagnosis of IHD is not included in the main classification used for heart disease in pregnancy: the modified World Health Organization (mWHO) classification, Denoble noted.
"This classification includes information on pregnancy outcomes in women with many cardiac conditions, including arrhythmias, congenital heart disease, heart failure, and aortic aneurysm, but [IHD] is missing," Denoble explained.
She suggested this is probably because IHD is regarded as a condition that occurs mainly in older people, "but we are seeing more and more women with [IHD] who are pregnant or considering pregnancy. This could be because women are now often older when considering pregnancy, and also risk factors for [IHD], such as obesity and diabetes, are becoming more frequent in younger women."
The researchers conducted the current study to investigate pregnancy outcomes for these women.
The retrospective cohort study analyzed data from the Nationwide Readmissions Database on women who had experienced a delivery hospitalization from October 1, 2015 to December 31, 2018. They compared outcomes for women with isolated preexisting IHD with those of women who had no apparent cardiac condition and with those of women with mild or more severe cardiac conditions included in the mWHO classification after controlling for other comorbidities.
The primary outcome was severe maternal morbidity or death. Denoble explained that severe maternal morbidity includes mechanical ventilation, blood transfusion, and hysterectomy: the more severe maternal adverse outcomes of pregnancy.
Results showed that of 11,556,136 delivery hospitalizations, 65,331 patients had another cardiac diagnosis, and 3009 had IHD alone. Patients with IHD were older, and rates of diabetes and hypertension were higher.
Of women with preexisting IHD, 6.6% experienced severe maternal morbidity or death compared with 1.5% of women without a cardiac disease (unadjusted relative risk [RR] compared with no cardiac disease 4.3 [95% CI: 3.5, 5.2]).
In comparison, 4.2% of women with mWHO I to II cardiac diseases and 23.1% of women with more severe mWHO II/III to IV cardiac diseases experienced severe maternal morbidity or death.
Similar differences were noted for nontransfusion severe maternal morbidity and mortality, as well as cardiac severe maternal morbidity and mortality.
After adjustment, IHD alone was associated with a higher risk for severe maternal morbidity or death compared with no cardiac disease (adjusted relative risk [aRR] 1.51 [95% CI: 1.19, 1.92]).
In comparison, the aRR was 1.9 (95% CI: 1.76, 2.06) for WHO class I to II diseases and 5.87 (95% CI: 5.49, 6.27) for more severe cardiac conditions defined as WHO II/III to IV diseases.
Risk for nontransfusion severe maternal morbidity or death (aRR 1.6 [95% CI: 1.11, 2.3]) and cardiac severe maternal morbidity or death (aRR 2.98 [95% CI: 1.75, 5.08]) were also higher for women with IHD than for women without any cardiac disease.
There were no significant differences in preterm birth for women with preexisting IHD compared with preterm birth for women with no cardiac disease after adjustment.
The risk for severe maternal morbidity and mortality, nontransfusion severe maternal morbidity and mortality, and cardiac severe maternal morbidity and mortality for IHD alone most closely approximated that of mWHO class I or II cardiac diseases, the researchers said.
"We found that individuals with preexisting [IHD] had a rate of severe maternal morbidity/mortality in the same range as those with other cardiac diagnoses in the mild cardiac disease classification (class I or II)," Denoble commented. "This prognosis suggests it is very reasonable for these women to consider pregnancy. The risk of adverse outcomes is not so high that pregnancy is contraindicated."
Denoble said this information will be very helpful when counseling women with preexisting IHD who are considering pregnancy.
"I would still advise these women to register with a high-risk obstetrics provider to have a baseline [CV] pregnancy evaluation. As long as that is reassuring, then further frequent intensive supervision may not be necessary," she said.
They added that other medical comorbidities should be factored into discussions regarding the risks for pregnancy.
The researchers also noted that the study was limited to evaluation of maternal outcomes occurring during the delivery hospitalization and that additional research that assesses rates of maternal adverse cardiac events and maternal morbidity occurring before or after the delivery hospitalization would be beneficial.
Future studies examining the potential gradation in risk associated with additional cardiac comorbidities in individuals with preexisting IHD would also be worthwhile, they added.
The study was supported by funding from the National Institutes of Health and the Foundation for Women and Girls with Blood Disorders. The authors have disclosed no relevant financial relationships.
JACC Adv. 2022:1:1-10.[1]
