The latest in women's heart health

In recent years, a pressing need and calls by those in the field have driven institutions and professional organizations to place a more focused effort on addressing and including women’s heart health as focal points of initiatives and campaigns, which extends to conferences and scientific meetings.

The agenda of the Heart Failure Society of America (HFSA) 2023 annual scientific meeting serve as an example of the results of these calls for a renewed emphasis on women’s heart health, with the meeting featuring multiple sessions and presentations related to women and heart failure, including highlighting contemporary trends in the Journal of Cardiac Failure with the inaugural HF Stats report.¹

In addition to the report, the Journal of Cardiac Failure also hosted a lecture series led by Nosheen Reza, MD, of the University of Pennsylvania, Ersilia DeFilippis, MD, of the Columbia University Irving Medical Center, and Martha Galati, MD, of Cedars-Sinai, spotlighting pregnancy and heart failure.

Below, we highlight a trio of posters related to women’s health in heart failure and cardiology from HFSA 2023.

Trends in Heart Failure Mortality in Premenopausal Women²

A presentation led by Sarath Lal Mannumbeth Renjithlal, MBBS, of Rochester Regional Health, and Sabu Thomas, MD, of the University of Rochester Medical Center, highlighted trends of heart failure associated mortality in premenopausal women in the US since the turn of the century. Using the CDC’s WONDER database, investigators performed a cross-sectional analysis with the intent of assessing age-adjusted mortality rates (AAMR) per 1,000,000 individuals and corresponding annual percentage changes (APC) among women within the database aged 15 to 55 years between 1999 and 2020.²

A total of 18,875 heart failure-related deaths were recorded from 1999 to 2020 among women aged 15 to 55 years. Analysis of annual trends indicates the AAMR double from 0.8 per million (95%CI 0.7-0.8) in 1999 to 1.6 per million (95% Confidence interval [CI], 1.5-1.6) in 2020. When assessing APC, investigators found there was no statistically significant change of APC of 0.91 (95% CI -0.2 to 2.0) from 1999 to 2011, but a significant increase in mortality with APC of 6.1 (95% CI, 4.5 to 7.8) from 2012 to 2020.

Investigators called attention to significant racial disparities in prevalence of heart failure-related mortality in their study, with the AAMR of black women almost 4 times the AAMR of white women of same age group (3.2 [95% CI, 3.1 to 3.2] vs 0.7 [95% CI, 0.7 to 0.7]).2

Hypertrophic Cardiomyopathy in Pregnancy³

A team led by Anas Alameh, MD, of the MetroHealth Medical Center, put a spotlight on hypertrophic cardiomyopathy ion pregnancy with a study capturing patient characteristics and outcomes from within the National Inpatient Sample from 2015 to 2020. Using the database, investigators performed a retrospective analysis comparing characteristics and outcomes among 187 pregnant women with and 3,599,855 pregnant without hypertrophic cardiomyopathy.³

Upon analysis of [patient characteristics, investigators called attention to an increased prevalence of hypertrophic cardiomyopathy among Black women, which they linked to differences in socioeconomic factors. Further analysis indicated patients with hypertrophic cardiomyopathy had increased odds of systemic organ disease, such as lung disease, renal failure, and obesity, as well as cardiovascular comorbidities, including cardiac arrhythmia, heart failure, valvular disease, and chronic hypertension. Analysis of outcomes suggested outcomes revealed women with hypertrophic cardiomyopathy were more likely to have preterm labor (Odds Ratio [OR], 3.64; P=.01), intrauterine death (OR, 3.6; P=.02), C-section (OR, 1.83; P <.01), and instrumental delivery (OR, 12.75; P=.02).³

Differences in Referral Driving Sex-Based Disparities in Heart Transplant⁴

Led by Priyesha Bijlani, MD, of University of California - San Diego (UCSD) Health, a team of investigators sought to better understand how sex differences in referral and evaluation might contribute to disparities in rates of women undergoing heart transplant. With this in mind, investigators designed their research endeavor as a single-center retrospective study pf adult heart failure patients referred for transplant at USCD Health from 2012 to 2022 using electronic medical record data.⁴

Among 36 million patients receiving care at UCSD Health during the study period, 55,506 were diagnosed with heart failure. Among these, 43.% were women and 56.5% were men. Overall, 1596 patients referred from the general community for consideration of heart transplantation.⁴

Upon analysis, a significant difference was observed between the rate of referral for women compared to their male counterparts, with women accounting for just 22.7% of referrals (P <.001). Investigators also pointed out women were less likely to be approved for transplantation following committee evaluation, with just 40.8% of women approved for a transplant compared to 48.1% of men (P =.05).

A subgroup analysis of 427 people deemed ineligible for evaluation for transplantation pointed to the presence of a trend toward more women being deemed ineligible for financial reasons (P=.10) and patient’s choice (P=.17) compared to men.⁴

For more on women’s heart health at HFSA 2023, check out this Q&A with Jenna Skowronski, MD, chief cardiology fellow at the University of Pittsburgh Medical Center.

HCPLive Cardiology: Can you describe what you view as an emphasis on women's heart health at HFSA 2023?

Skowronski: As a trainee, contemplating entering a specialized niche where heart failure is at the core of concern is something I think that many of us consider. However, when we delve into the realm of women's cardiology, particularly heart failure during pregnancy, we encounter a vastly underserved need that often inspires apprehension. It's almost as though pregnant women in cardiology are met with reluctance; people tend to shy away from this area.

Also, many of the issues related to pregnancy and cardio-obstetrics within heart failure may initially seem beyond our purview, but I firmly believe they fall well within it. For instance, one aspect I'm particularly passionate about is addressing contraception for these patients.

As heart failure attendings, we often prescribe medications with potential fetal toxicity, as well as medications that can impact a woman's ability to breastfeed. We really need to be to engage in conversations about contraception for these women and make it a shared decision-making process to ensure we fully take care of them as people rather than just focusing on one aspect of their health.

There are a lot of exciting developments in the field of cardio-obstetrics and, as a trainee, it's exciting to be part of this evolving landscape.

HCPLive Cardiology: With what you described in mind, how important is having these conversations with patients sooner rather than later to best reduce risk of adverse outcomes?

Skowronski: If women are coming into your office while pregnant and you have not yet discussed their reproductive health with them, I think that is an unfortunate situation.In my perspective, the conversation should begin the very first time you meet them. It's crucial to take a reproductive history for every patient of childbearing age under your care.

From this history, you can approach the conversation with curiosity. You might ask questions like, 'Have you considered having children or becoming pregnant? Is it something that interests you? Have you faced any difficulties with pregnancy in the past?' Understanding where the patient stands is key, and it allows you to tailor your approach accordingly.

Ideally, pregnancies should be planned, not accidental. Discussing contraception during the initial visit is essential. I can't stress enough how important it is to initiate this conversation from the beginning and continue to revisit it over time. A person's feelings about pregnancy can change over the years. What they think at 25 may not be the same when they're 30, so it's crucial to keep addressing the topic.

Certainly, you don't want to frighten anyone. Patients who feel that they have a say in their care, and that their healthcare providers are attentive, are more likely to be receptive. Honesty about the associated risks is necessary.

For instance, if a patient has severe group one pulmonary arterial hypertension, pregnancy becomes a high-risk situation. It's okay to say that, given your skill set and knowledge, pregnancy isn't recommended. Simultaneously, make it clear that even if they were to become pregnant, you'd still be their doctor, providing excellent care and listening to their needs.

When patients feel heard and believe they have a say in their care, you can have these challenging conversations about risk and reassure them that you'll be there for them, regardless of the circumstances.

HCPLive Cardiology: How important is finding the right balance of patient education versus overinforming when it comes to cardiovascular health in women?

Skowronski: It's important not to instill fear in anyone. Patients who feel empowered in their healthcare, those who believe their physicians and providers truly listen to them, are more open to what you have to say. Being honest with your patients about the associated risks is essential.

For instance, if you're dealing with a severe case of group one pulmonary arterial hypertension (PAH), a pregnancy would be high risk. It's acceptable to convey that, given the appropriate skill set and knowledge, pregnancy may not be the recommended path. Simultaneously, make it clear that even if they were to become pregnant, you would remain their doctor, providing excellent care and attending to their needs.

When patients feel heard and in control of their healthcare decisions, it becomes easier to engage in these challenging conversations about risk and reassure them that you'll stand by their side, no matter the circumstances

Editor’s note: This transcript has been edited for grammar and clarity using artificial intelligence.

This article was published by our sister publication HCP Live.

References:

1. Heart failure (HF) rate expected to rise to 8.5 million Americans by 2030. new HFSA initiative identifies rapidly changing landscape of HF in the U.S. HFSA. October 3, 2023. Accessed October 13, 2023. https://hfsa.org/heart-failure-hf-rate-expected-rise-85-million-americans-2030-new-hfsa-initiative-identifies.
2. Mannumbeth Renjithlal SL, Thomas S. Trends Of Heart Failure Associated Mortality In Pre-menopausal Women In The United States 1999-2020. Paper presented at: Heart Failure Society of America 2023 Annual Scientific Meeting; October 6 - 9; Cleveland, OH. Accessed October 12, 2023.
3. Alameh A, Jabri A, Sukhon F, et al. Hypertrophic Cardiomyopathy In Pregnancy: A Retrospective Study Of Patients Characteristics And Outcomes. Paper presented at: Heart Failure Society of America 2023 Annual Scientific Meeting; October 6 - 9; Cleveland, OH. Accessed October 12, 2023.
4. Biijlani P, Cusi V, Birs A, et al. Sex Differences In Referral And Evaluation Lead To Lower Rates Of Heart Transplant In Women. Paper presented at: Heart Failure Society of America 2023 Annual Scientific Meeting; October 6 - 9; Cleveland, OH. Accessed October 12, 2023.