Downloaded from http://heart.bmj.com/ on March 16, 2015 - Published by group.bmj.com
Editorial
Coronary disease in pregnancy Anna Polewczyk Coronary heart disease (CHD), together with its most serious manifestation—acute coronary syndrome (ACS), seldom occurs in women during pregnancy. However, the real frequency of stable CHD and ACS is difficult to assess, considering the scarcity of precise data. The majority of reports estimate only the incidence of acute myocardial infarction resulting in conflicting rates of CHD/ACS in the literature with an incidence around 1 in 36 000 to 1 in 16 000 deliveries.1 According to the data from the current Registry Of Pregnancy And Cardiac disease (ROPAC), CHD is observed in 2% of pregnant women (based on data from 2007 forward), with about 3000 patients with structural heart diseases.2 Presently, we are witnessing an increased mortality rate in pregnant women, probably due to cardiovascular events. According to the US Pregnancy Mortality Surveillance System, the aggregate pregnancy-related mortality ratio (for the 8-year period, 1998–2005) was 14.5 per 100 000 live births, which is higher than any period in the previous 20 years. Additionally, deaths associated with medical conditions, especially cardiovascular conditions, account for an increasing percentage of pregnancyrelated deaths.3 Similarly, in the UK, deaths due to cardiovascular diseases in pregnancy have been increasing over the past 30 years, with a recent incidence of around 2.3 per 100 000 maternities. Coronary disease contributed to 20% of these deaths equating to a death rate of 0.48 per 100 000 maternities due to CHD.1 In view of this data, studies assessing the risk of cardiovascular complications in women during pregnancy are of great clinical importance. Burchill et al4 used the ROPAC data to analyse the rarely (up to now) discussed problem of a potentially higher risk of adverse events in subsequent pregnancies in women with a history of coronary incidents. Atherosclerosis was the most often substrate of CHD in study population. Risk factors for coronary artery disease in pregnancy appear to be similar to those traditionally observed in the general Correspondence to Dr Anna Polewczyk, II Department of Cardiology, Swietokrzyskie Cardiology Center, Grunwaldzka Street 45, Kielce 25-736, Poland; [email protected] 502
population, including: smoking, family history, hypertension, dyslipidaemia, obesity and diabetes. In the current study, the presence of at least one of the above factors was confirmed in 82% of pregnant women with the most common being a history of cigarette smoking (almost 60% of patients). According to the ROPAC registry, smoking, hypertension and diabetes are also significantly more common in patients with CHD.2 Additional coronary risk factors in pregnant women are older age and multiparity. In the present study, the correlation of these factors with adverse events during the following pregnancy was not confirmed, however, the majority of women were multiparous and the mean study age was relatively high (34 ±5 years). Similarly, the direct relationship between typical coronary risk factors and adverse cardiovascular events was not observed although maternal cardiac events were more common in women with CHD due to coronary atherosclerosis. The demonstration that known pre-existing CHD is associated with worse outcomes for the following pregnancy confirms that gestation, per se, may escalate the risk of myocardial ischaemia. Although pregnancy itself has not been regarded as a risk factor for cardiac adverse events, previous studies have indicated that the risk of ACS is approximately three to four times higher during pregnancy compared with nonpregnant women of reproductive age.5 The impact of pregnancy on the progression of ischaemic heart disease is not fully understood, but there are a number of hypotheses trying to explain this phenomenon. Pregnancy is a prothrombotic state with associated vascular dysfunction. Hypercoagulability in pregnancy results from increased fibrinogen levels and physiological anaemia; myocardial oxygen supply is decreased due to a lower diastolic blood pressure. In patients with coronary lesions, these factors may induce anginal pain and even deterioration of cardiac function. Birth-related pain and effort, as well as sudden changes in blood volume and pressure postpartum, may also significantly increase the risk of cardiovascular complications.6 7 Circulating blood volume, cardiac output and heart rate can increase by up to 50% causing a rising demand Polewczyk A. Heart April 2015 Vol 101 No 7
for oxygen. Moreover, hormonal substances seem to have significant influence on (at that time) vulnerable vessels. Progesterone has been linked with smooth muscle hyperplasia, reduction in acid mucopolysaccharides and weakening of the arterial wall. Oestrogens have shown to increase the activity of matrix metalloproteinases, which may also lead to breakdown of the medial layer within the artery. Circulating relaxin, which also helps to prepare the female pelvis for delivery, causes inhibition of endothelin-1 stimulation, which can further exacerbate endothelial dysfunction.1 8 The complex pathogenic mechanisms that are probably responsible for exacerbation of coronary disease during pregnancy may also induce the development of ACS from other causes observed in pregnant women: including coronary embolism, coronary dissection or coronary spasm. Consequently, the high frequency of ischaemic cardiac events (new or progressive angina, ACS/MI, ventricular arrhythmia, cardiac arrest) complicating 26% of pregnancies seen in the present study confirms the influence of normal changes with pregnancy on the risk of cardiovascular complications in women with known CHD. Additionally, there was high frequency of adverse obstetric (16%) and fetal/neonatal events (30%). It is important to recognise that the highest number of these events (particularly fetal/neonatal) was observed in women with coronary atherosclerosis. Fortunately, the mortality rate (both maternal and neonatal) was lower than previously reported (2% in the current study in comparison with 9%–13% in the literature)1 5) The authors emphasise that studied patients were taken good care of (all were followed in tertiary cardiac care programmes), many of them had undergone revascularisation and, in the majority, LVEF was preserved. Data of the impact of previous CHD on the course of subsequent pregnancies is scarce, making the data from this present multicentre study valuable, especially from a clinical point of view. The increased frequency of complications in pregnant women with known underlying CHD, especially due to atherosclerosis should lead to increased attention to reduction of modified risk factors in these patients. Additionally, women with known coronary artery disease should undergo assessment by a cardiologist before pregnancy. This evaluation should include a basic physical examination, ECG, echocardiogram and exercise test, if necessary. In
Downloaded from http://heart.bmj.com/ on March 16, 2015 - Published by group.bmj.com
Editorial many patients, coronary CT or coronary angiography also may be appropriate. Women with significantly decreased ventricular function, heart failure symptoms, angina pectoris or advanced changes in coronary arteries should be discouraged from getting pregnant. As this study illustrates, pregnant women with known CHD or cardiac risk factors require specialist care provided by an experienced obstetric and cardiac team.
Published Online First 21 January 2015
5
▸ http://dx.doi.org/10.1136/heartjnl-2014-306676 Heart 2015;101:502–503. doi:10.1136/heartjnl-2014-307289
6
REFERENCES
7
1
Competing interests None. Provenance and peer review Commissioned; internally peer reviewed.
2
3
To cite Polewczyk A. Heart 2015;101:502–503.
Polewczyk A. Heart April 2015 Vol 101 No 7
4
Fryearson J, Adamson DL. Heart disease in pregnancy: ischaemic heart disease. Best Pract Res Clin Obstet Gynaecol 2014;28:551–62. Roos-Hesselink JW, Ruys TP, Stein JI, et al; ROPAC Investigators. Outcome of pregnancy in patients with structural or ischaemic heart disease: results of a registry of the European Society of Cardiology. Eur Heart J 2013;34:657–65. Berg CJ, Callaghan WM, Henderson Z, et al. Pregnancy-Related Mortality in the United States, 1998 to 2005. Obstet Gynecol 2011;117:1230.
8
Burchill LJ, Lameijer H, Roos-Hesselink JW, et al. Pregnancy risks in women with pre-existing coronary artery disease or following acute coronary syndromes. Heart 2015;101:525–9. James AH, Jamison MG, Biswas MS, et al. Acute myocardial infarction in pregnancy: a United States population-based study. Circulation 2006;113: 1564–71. Janion-Sadowska A, Sadowski M, Kurzawski J, et al. Pregnancy after acute coronary syndrome: a proposal for patients’ management and a literature review. Biomed Res Int 2013;2013:957027. Kealey A. Coronary artery disease and myocardial infarction in pregnancy: a review of epidemiology, diagnosis, and medical and surgical management. Can J Cardiol 2010;26:185–9. Appleby CE, Barolet A, Ing D, et al. Contemporary management of pregnancy-related coronary artery dissection: a single centre experience and literature review. Exp Clin Cardiol 2009;14:e8–16.
503
Downloaded from http://heart.bmj.com/ on March 16, 2015 - Published by group.bmj.com
Coronary disease in pregnancy Anna Polewczyk Heart 2015 101: 502-503 originally published online January 21, 2015
doi: 10.1136/heartjnl-2014-307289 Updated information and services can be found at: http://heart.bmj.com/content/101/7/502
These include:
References Email alerting service
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This article cites 7 articles, 2 of which you can access for free at: http://heart.bmj.com/content/101/7/502#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Articles on similar topics can be found in the following collections Drugs: cardiovascular system (8119) Epidemiology (3354) Hypertension (2756) Tobacco use (577) Acute coronary syndromes (2544)
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
Editorial
Coronary disease in pregnancy Anna Polewczyk Coronary heart disease (CHD), together with its most serious manifestation—acute coronary syndrome (ACS), seldom occurs in women during pregnancy. However, the real frequency of stable CHD and ACS is difficult to assess, considering the scarcity of precise data. The majority of reports estimate only the incidence of acute myocardial infarction resulting in conflicting rates of CHD/ACS in the literature with an incidence around 1 in 36 000 to 1 in 16 000 deliveries.1 According to the data from the current Registry Of Pregnancy And Cardiac disease (ROPAC), CHD is observed in 2% of pregnant women (based on data from 2007 forward), with about 3000 patients with structural heart diseases.2 Presently, we are witnessing an increased mortality rate in pregnant women, probably due to cardiovascular events. According to the US Pregnancy Mortality Surveillance System, the aggregate pregnancy-related mortality ratio (for the 8-year period, 1998–2005) was 14.5 per 100 000 live births, which is higher than any period in the previous 20 years. Additionally, deaths associated with medical conditions, especially cardiovascular conditions, account for an increasing percentage of pregnancyrelated deaths.3 Similarly, in the UK, deaths due to cardiovascular diseases in pregnancy have been increasing over the past 30 years, with a recent incidence of around 2.3 per 100 000 maternities. Coronary disease contributed to 20% of these deaths equating to a death rate of 0.48 per 100 000 maternities due to CHD.1 In view of this data, studies assessing the risk of cardiovascular complications in women during pregnancy are of great clinical importance. Burchill et al4 used the ROPAC data to analyse the rarely (up to now) discussed problem of a potentially higher risk of adverse events in subsequent pregnancies in women with a history of coronary incidents. Atherosclerosis was the most often substrate of CHD in study population. Risk factors for coronary artery disease in pregnancy appear to be similar to those traditionally observed in the general Correspondence to Dr Anna Polewczyk, II Department of Cardiology, Swietokrzyskie Cardiology Center, Grunwaldzka Street 45, Kielce 25-736, Poland; [email protected] 502
population, including: smoking, family history, hypertension, dyslipidaemia, obesity and diabetes. In the current study, the presence of at least one of the above factors was confirmed in 82% of pregnant women with the most common being a history of cigarette smoking (almost 60% of patients). According to the ROPAC registry, smoking, hypertension and diabetes are also significantly more common in patients with CHD.2 Additional coronary risk factors in pregnant women are older age and multiparity. In the present study, the correlation of these factors with adverse events during the following pregnancy was not confirmed, however, the majority of women were multiparous and the mean study age was relatively high (34 ±5 years). Similarly, the direct relationship between typical coronary risk factors and adverse cardiovascular events was not observed although maternal cardiac events were more common in women with CHD due to coronary atherosclerosis. The demonstration that known pre-existing CHD is associated with worse outcomes for the following pregnancy confirms that gestation, per se, may escalate the risk of myocardial ischaemia. Although pregnancy itself has not been regarded as a risk factor for cardiac adverse events, previous studies have indicated that the risk of ACS is approximately three to four times higher during pregnancy compared with nonpregnant women of reproductive age.5 The impact of pregnancy on the progression of ischaemic heart disease is not fully understood, but there are a number of hypotheses trying to explain this phenomenon. Pregnancy is a prothrombotic state with associated vascular dysfunction. Hypercoagulability in pregnancy results from increased fibrinogen levels and physiological anaemia; myocardial oxygen supply is decreased due to a lower diastolic blood pressure. In patients with coronary lesions, these factors may induce anginal pain and even deterioration of cardiac function. Birth-related pain and effort, as well as sudden changes in blood volume and pressure postpartum, may also significantly increase the risk of cardiovascular complications.6 7 Circulating blood volume, cardiac output and heart rate can increase by up to 50% causing a rising demand Polewczyk A. Heart April 2015 Vol 101 No 7
for oxygen. Moreover, hormonal substances seem to have significant influence on (at that time) vulnerable vessels. Progesterone has been linked with smooth muscle hyperplasia, reduction in acid mucopolysaccharides and weakening of the arterial wall. Oestrogens have shown to increase the activity of matrix metalloproteinases, which may also lead to breakdown of the medial layer within the artery. Circulating relaxin, which also helps to prepare the female pelvis for delivery, causes inhibition of endothelin-1 stimulation, which can further exacerbate endothelial dysfunction.1 8 The complex pathogenic mechanisms that are probably responsible for exacerbation of coronary disease during pregnancy may also induce the development of ACS from other causes observed in pregnant women: including coronary embolism, coronary dissection or coronary spasm. Consequently, the high frequency of ischaemic cardiac events (new or progressive angina, ACS/MI, ventricular arrhythmia, cardiac arrest) complicating 26% of pregnancies seen in the present study confirms the influence of normal changes with pregnancy on the risk of cardiovascular complications in women with known CHD. Additionally, there was high frequency of adverse obstetric (16%) and fetal/neonatal events (30%). It is important to recognise that the highest number of these events (particularly fetal/neonatal) was observed in women with coronary atherosclerosis. Fortunately, the mortality rate (both maternal and neonatal) was lower than previously reported (2% in the current study in comparison with 9%–13% in the literature)1 5) The authors emphasise that studied patients were taken good care of (all were followed in tertiary cardiac care programmes), many of them had undergone revascularisation and, in the majority, LVEF was preserved. Data of the impact of previous CHD on the course of subsequent pregnancies is scarce, making the data from this present multicentre study valuable, especially from a clinical point of view. The increased frequency of complications in pregnant women with known underlying CHD, especially due to atherosclerosis should lead to increased attention to reduction of modified risk factors in these patients. Additionally, women with known coronary artery disease should undergo assessment by a cardiologist before pregnancy. This evaluation should include a basic physical examination, ECG, echocardiogram and exercise test, if necessary. In
Downloaded from http://heart.bmj.com/ on March 16, 2015 - Published by group.bmj.com
Editorial many patients, coronary CT or coronary angiography also may be appropriate. Women with significantly decreased ventricular function, heart failure symptoms, angina pectoris or advanced changes in coronary arteries should be discouraged from getting pregnant. As this study illustrates, pregnant women with known CHD or cardiac risk factors require specialist care provided by an experienced obstetric and cardiac team.
Published Online First 21 January 2015
5
▸ http://dx.doi.org/10.1136/heartjnl-2014-306676 Heart 2015;101:502–503. doi:10.1136/heartjnl-2014-307289
6
REFERENCES
7
1
Competing interests None. Provenance and peer review Commissioned; internally peer reviewed.
2
3
To cite Polewczyk A. Heart 2015;101:502–503.
Polewczyk A. Heart April 2015 Vol 101 No 7
4
Fryearson J, Adamson DL. Heart disease in pregnancy: ischaemic heart disease. Best Pract Res Clin Obstet Gynaecol 2014;28:551–62. Roos-Hesselink JW, Ruys TP, Stein JI, et al; ROPAC Investigators. Outcome of pregnancy in patients with structural or ischaemic heart disease: results of a registry of the European Society of Cardiology. Eur Heart J 2013;34:657–65. Berg CJ, Callaghan WM, Henderson Z, et al. Pregnancy-Related Mortality in the United States, 1998 to 2005. Obstet Gynecol 2011;117:1230.
8
Burchill LJ, Lameijer H, Roos-Hesselink JW, et al. Pregnancy risks in women with pre-existing coronary artery disease or following acute coronary syndromes. Heart 2015;101:525–9. James AH, Jamison MG, Biswas MS, et al. Acute myocardial infarction in pregnancy: a United States population-based study. Circulation 2006;113: 1564–71. Janion-Sadowska A, Sadowski M, Kurzawski J, et al. Pregnancy after acute coronary syndrome: a proposal for patients’ management and a literature review. Biomed Res Int 2013;2013:957027. Kealey A. Coronary artery disease and myocardial infarction in pregnancy: a review of epidemiology, diagnosis, and medical and surgical management. Can J Cardiol 2010;26:185–9. Appleby CE, Barolet A, Ing D, et al. Contemporary management of pregnancy-related coronary artery dissection: a single centre experience and literature review. Exp Clin Cardiol 2009;14:e8–16.
503
Downloaded from http://heart.bmj.com/ on March 16, 2015 - Published by group.bmj.com
Coronary disease in pregnancy Anna Polewczyk Heart 2015 101: 502-503 originally published online January 21, 2015
doi: 10.1136/heartjnl-2014-307289 Updated information and services can be found at: http://heart.bmj.com/content/101/7/502
These include:
References Email alerting service
Topic Collections
This article cites 7 articles, 2 of which you can access for free at: http://heart.bmj.com/content/101/7/502#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Articles on similar topics can be found in the following collections Drugs: cardiovascular system (8119) Epidemiology (3354) Hypertension (2756) Tobacco use (577) Acute coronary syndromes (2544)
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
![[Pregnancy and coronary artery dissection].](/assets/img/hold.png)
