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Pregnancy, sex differences important areas of women’s CV health
Recent ACC meeting called attention to CVD in women, but increased awareness is warranted.
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The American College of Cardiology Scientific Session, held in March in Washington, D.C., encompassed a wide breadth of topics, ranging from the latest in structural heart interventions to discussion of the newest lipid-lowering therapies. As experts from around the world gathered to discuss a multitude of topics, two programs focused on CV health in women particularly stood out to me. As rates of CVD and associated risk factors are high in women, and often go unnoticed, growing attention in this area is vital.
Pregnancy and CVD
At the meeting, the “Consequences of sex: Women and pregnancy across the spectrum” session focused on a wide variety of pregnancy-related topics and the association with peripartum CV conditions as well as long-term CV risk.
The increasing rates of maternal mortality and morbidity in the United States in the past few decades in comparison to other modern countries were a key point of discussion. Afshan B. Hameed, MD, clinical professor of obstetrics and gynecology in the School of Medicine at University of California, Irvine, highlighted representative data from California, noting that most postpartum deaths occur secondary to undiagnosed CV conditions.
The associated mortality risk with CV conditions such as congenital heart disease and aortic disease, among others, is well-known. However, an important point from this presentation is that high-risk women are not just those with known CV conditions, but other more standard medical history such as age older than 40 years, substance abuse history, black race, pre-existing diabetes or hypertension. Additionally, women with a history of previous CV symptoms such as HF and arrhythmias should also be considered high risk.
Hameed also provided an excellent review of several risk scores designed to risk-stratify women with CV conditions, including CARPREG, WHO and ZAHARA.
To highlight the complexity of managing patients with known CV conditions, Uri Elkayam, MD, professor of medicine and professor of obstetrics and gynecology at the University of Southern California and a Cardiology Today Editorial Board Member, presented a series of cases highlighting postpregnancy CV complications. This is particularly important, because as the number of patients with congenital heart disease maturing into adulthood increases, there is a larger potential group of women with these conditions who will have children despite warnings otherwise from their pediatric cardiologists.
Along these lines, having an interdisciplinary team is crucial. Doreen DeFaria Yeh, MD, associate director of the Adult Congenital Heart Disease Program and co-director of the Cardiovascular Disease and Pregnancy Service at Massachusetts General Hospital, provided an insightful overview of how to develop a cardio-obstetrics program using a multidisciplinary approach to care for these complex patients. A particularly innovative component of such a program is providing interdisciplinary education across specialties such that cardiology fellows learn about the basic stages of labor, for instance, while the obstetrics residents learn basic ECG findings. Such interaction can also facilitate research and clinical collaborations between such groups.
Once the immediate postpartum period is over, patients and providers may not appreciate the hidden long-term CV risks associated with various adverse pregnancy conditions. Janet M. Catov, PhD, MS, associate professor in the department of obstetrics, gynecology and reproductive sciences and the department of epidemiology at the University of Pittsburgh, discussed utilizing pregnancy as a woman’s first physiologic stress test. This session was particularly enlightening, as Catov has performed extensive epidemiologic research in the area of adverse pregnancy outcomes such as preeclampsia and long-term CV risk. Such work highlights the potential for adverse pregnancy conditions to serve as a marker for aggressive CV risk reduction efforts in an otherwise seemingly healthy population of young women.
Sex differences
Another enlightening session entitled, “Is there really a sex difference in CV presentation, care, and outcomes?” was highlighted. This session utilized a debate-style format to discuss a variety of sex-related issues across cardiac care, symptom assessment and treatment. This was a particularly important session because sex-based differences in various CV conditions are often advertised, but what exactly these differences are and how they clinically translate are not well understood.
Jennifer Tremmel, MD, assistant professor of medicine (cardiovascular medicine) at Stanford University Medical Center, first highlighted the importance of differentiating between “sex” and “gender.” Sex is a biologic term aligned with presence of reproductive organs and functions. Conversely, gender is a psychosocial term of self-representation or how a person is presented in the setting of a social situation on the basis of the individual’s gender presentation. These terms may overlap in discussion of both biologic and social elements, thus sex/gender used together may be appropriate. It is important to note these differences so that these terms may be appropriately utilized in the literature and in the media.
Regarding gender bias, the sessions noted existing differences in under-recognition of symptoms in women and timeliness of evaluation of symptoms in women compared with men and referral to diagnostic procedures including cardiac catheterization. Regarding symptoms, it has often been noted that women present with atypical symptoms of angina compared with men. However, Annabelle Volgman, MD, professor at Rush University Medical Center in Chicago, noted that the recent 10,000-participant PROMISE study included an equal percentage of men and women presenting with symptoms of chest pain. However, although some differences in symptoms exist, the underlying pathology likely differs because women tend to suffer disproportionately from microvascular coronary dysfunction. Women are also less likely to receive secondary prevention measures such as cardiac rehabilitation. The “con” to this topic presented data that considering the differences in women presentation vs. men, the gender bias for catheterization referral is in fact not sustained based on traditional appropriate use criteria. Additionally, the presenter argued that both women and men are under-referred for secondary prevention measures, and as such, gender or sex may not be the predominant issue alone.
Women’s heart health clinics
The final discussion took on the topic of the need for dedicated women’s heart health clinics. On one hand, there are definitive conditions/risk factors for CVD, most prominently adverse pregnancy conditions, which are not well appreciated by most primary care providers or obstetricians. However, it was also argued that overall CV mortality in women has declined in the past decade, reflecting adequate education efforts such as Go Red for Women, and that differences in treatment and symptomatology are not as disparate as has been portrayed.
Regardless of presentation, whatever differences that do exist in CV conditions/therapies in men and women should be recognized and education is the key element. Women’s heart clinics provide a stopgap to provide targeted care for women, particularly for issues such as hormone replacement therapy and adverse pregnancy outcomes. However, these clinics should not serve as a substitute for continued education to general providers and cardiologists.
More attention, investigation needed
Although conclusions may not be definitive, it can be taken away that issues regarding women’s CV health remain important and require more investigation. As I sat through these sessions it was notable that one thing was missing — men in the audience. This is unfortunate, as it is not just women providers seeing women in clinical practice. Women’s CV health should be an important topic for any provider regardless of subspecialty or gender. Thus, efforts to improvement education and advocacy in this area remain important.
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- Ki Park, MD, MS, FSCAI, is an assistant professor in interventional cardiology at University of Florida and Malcom Randall VA Medical Center, Gainesville. Park is also a Cardiology Today Next Gen Innovator. She can be reached at ki.park@medicine.ufl.edu.
Disclosure: Park reports no relevant financial disclosures.