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Complications during pregnancy linked to a higher risk of heart disease, study finds

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CNN
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Five major pregnancy complications are strong lifelong risk factors for ischemic heart disease, a new study finds, with the greatest risk coming in the decade after delivery.

Ischemic heart disease refers to heart problems, including heart attack, caused by narrowed or dysfunctional blood vessels that reduce blood and oxygen flow to the heart.

Gestational diabetes and preeclampsia increased the risk of ischemic heart disease in the study by 54% and 30%, respectively, while other high blood pressure disorders during pregnancy doubled the risk. Delivering a baby early – before 37 weeks – or delivering a baby with a low birth weight were associated with a 72% and 10% increased risk, respectively.

The study, published in Wednesday in the BMJ, followed a cohort of more than 2 million women in Sweden with no history of heart disease who gave birth to single live infants between 1973 and 2015.

Roughly 30% of the women had at least one adverse pregnancy outcome. Those who had multiple adverse outcomes – whether in the same or different pregnancies – showed further increased risk of ischemic heart disease.

“These pregnancy outcomes are early signals for future risk of heart disease and can help identify high-risk women earlier and enable earlier interventions to improve their long-term outcomes and help prevent the development of heart disease in these women,” said Dr. Casey Crump, an author of the study and professor of family medicine at the Icahn School of Medicine at Mount Sinai.

Heart disease is the leading cause of death among women in the United States and accounts for 1 in 5 female deaths, according to the US Centers for Disease Control and Prevention. This research adds to mounting evidence that pregnancy provides important information about a woman’s cardiovascular health.

“What happens to a woman during pregnancy is almost like a stress test or a marker for her future cardiovascular risk after pregnancy. And unfortunately, a lot of women don’t get told this by anybody,” said CNN Medical Correspondent Dr. Tara Narula, an associate professor of cardiology and the associate director of the Women’s Heart Program at Lenox Hill Hospital. She was not involved in the new study.

Although it’s not completely clear why, experts say the normal changes that occur during pregnancy may unmask underlying health issues in some women with certain risk factors.

Experiencing an adverse pregnancy outcome – even temporarily – could result in changes to blood vessels and the heart that may persist or progress after delivery, increasing a woman’s risk for cardiovascular disease.

This heightened risk is a particular concern for women in the US, experts say, where the maternal mortality rate is several times higher than in other high-income countries.

“There’s been a change in the birthing population. US women are getting pregnant at a later age, and they have already accrued maybe one or two cardiovascular risk factors. Perhaps there are other stressors in life – depression, stress, isolation, obesity – lots of different things that are impacting women in the US,” said Dr. Garima Sharma, associate professor of cardiology and director of the Cardio-Obstetrics Program at Johns Hopkins University School of Medicine, who also was not involved in the new study.

Pregnancy complications are carefully monitored during pregnancy, but there is little evaluation of and education about the effects on cardiovascular health after delivery for women, experts say.

“And so they have their delivery, they’ve had maybe preeclampsia or gestational diabetes, and nobody really follows up with them. They are not told that, in fact, they are at increased risk,” Narula said.

Gestational diabetes is a marker not only for increased risk of diabetes but also for general cardiovascular disease. Preeclampsia and eclampsia are markers for hypertension risk as well as general cardiovascular risks.

Narula, a cardiologist who specializes in caring for women, regularly considers adverse pregnancy outcomes when evaluating patients and emphasizes the continued need for this.

“The classic risk calculator that we use doesn’t have anything in there for pregnancy complications, but you know, it should for women, and hopefully someday, they will start to take that into account,” she said.

The American Heart Association recommends that all health care professionals take a detailed history of pregnancy complications when assessing a woman’s heart disease risk, but this is not consistently done in clinical practice, especially in primary care, where most women are seen, Crump says.

“Raising awareness of these findings among physicians as well as women hopefully will enable more of these women to be screened early and hopefully improve their long-term outcomes,” he said.

Roughly 1 in 3 women will have an adverse pregnancy outcome. Experts say that improving your health before getting pregnant can help avoid these issues.

“Reducing your risk should start preconception, and so getting your body and yourself into the healthiest state possible before you ever even get pregnant is really the first step,” Narula said.

This includes achieving and maintaining a healthy body weight with a good diet and regular exercise, controlling high blood pressure and diabetes, quitting smoking and managing stress.

Taking action after pregnancy is equally important, as research has estimated that only 30% to 80% of women have a postpartum checkup 6 to 8 weeks after delivery.

“Making sure that these women actually are appropriately followed after their delivery and that there is a warm handoff between [obstetrics] and [maternal-fetal medicine] to their primary care doctors or preventive cardiologists who can then talk about optimizing cardiovascular risks and reduction of these risk factors post-pregnancy in the postpartum time frame is crucial,” Sharma said.

Experts hope that increased patient and provider awareness of the connection between pregnancy and heart health will keep birth from being a cause of death.

“Cardiovascular disease is preventable. It’s a leading cause of maternal mortality, but it doesn’t have to be. If we do a better job at screening patients before they get pregnant, if we do a better job of treating them during pregnancy and postpartum, we can improve women’s outcomes,” Narula said. “It’s a tragedy to bring a new life into the world, and then the mother suffers some horrible complication and/or death that could have been prevented.”

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Lower your blood pressure to this number to reduce risk of severe Covid, study finds

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CNN
 — 

High blood pressure is a known risk factor for a bout of Covid-19 severe enough to raise the specter of hospitalization and death. In fact, research has shown having high blood pressure doubles the risk of having a severe case of Covid, even if you are fully vaccinated and boosted.

Blood pressure is measured in units of millimeters of mercury (abbreviated as mmHg), which consists of two numbers — an upper or systolic reading that represents the maximum amount of pressure in your arteries, and the lower or diastolic reading that shows the pressure in your arteries when your heart muscle is at rest between beats.

But what is considered a high enough blood pressure reading to trigger that risk? To date, scientists haven’t been sure. Now, a new study out of England published Wednesday in the journal PLOS One has answered that question.

“We found that in those with diagnosed hypertension, the risk of Covid-19 significantly increased once the high number exceeded 150 mmHg or the low number exceeded 90 mmHg compared to a target blood pressure (120-129/80-89 mmHg),” said lead author Holly Pavey, a doctoral student at the University of Cambridge in the United Kingdom who is funded by the British Heart Foundation, via email.

The research found people with this level of uncontrolled high blood pressure are more likely to be admitted to the hospital and die from a Covid infection, regardless of other known risk factors such as age, ethnicity or obesity.

The new study was able to drill down and be more specific because of the inherent integration in the UK National Health Service. That level of data sharing allows access to “really granular data on long-term blood pressure control for their patients,” said Dr. Joseph Ebinger, an assistant professor of cardiology and director of clinical analytics of the Smidt Heart Institute at the Cedars-Sinai Medical Center in Los Angeles.

“They found it’s not just the diagnosis of high blood pressure — yes or no — but that the risk goes up as your systolic blood pressure goes up, which is really a measure of lack of control,” said Ebinger, who was not involved in the study.

Unfortunately, many people fail to properly control their blood pressure, even after they have been diagnosed and are on medication, Ebinger added.

“It’s estimated that less than half of individuals with a diagnosis of high blood pressure actually have control over their hypertension, so this is a big problem,” he said. “That’s due to a myriad of factors: underdiagnosis, lack of awareness, medication nonadherence and undertreatment.”

On the positive side, successfully reducing blood pressure through medication was linked with a corresponding reduction in risk for severe Covid, the new study found.

“It is really important for individuals to have regular blood pressure checks and for doctors to try and get their patients’ blood pressure controlled,” Pavey said.

“Controlling the blood pressure to target levels is important, irrespective of the type of treatment used to achieve it,” she said. “Ultimately blood pressure control will help to reduce the risk of suffering severely from new strains of Covid-19 or other viruses in the future.”

Blood pressure readings can be confusing — there are a lot of numbers tossed around, and medical professionals haven’t exactly made it easy for people to follow along.

“Normal” blood pressure readings are typically 120 mmHg systolic (upper reading) over 80 mmHg dystolic (lower reading), according to the US Centers for Disease Control and Prevention.

That’s likely the number you’ll hear mentioned most often. However, that may not be the number your doctor uses to treat you, Ebinger said.

Doctors used to target a blood pressure reading of less than 140/90 to control risk for cardiovascular disease and death, he explained. Then, in 2015, results of SPRINT, or the Systolic Blood Pressure Intervention Trial, were published in The New England Journal of Medicine — findings that changed the thinking of many medical professionals.

The SPRINT research found targeting a blood pressure below 120 systolic (the top number) in people with hypertension — but no diabetes — prevented the most cases of heart disease and death. There were some side effects, however, including a “higher rate of acute kidney injury or acute renal failure in the intensive-treatment group,” according to the trial.

That possibility was concerning when it came to the elderly, who often have multiple chronic diseases such as type 2 diabetes, kidney concerns and more, Ebinger said.

“So in 2017, the American College of Cardiology and American Heart Association guidelines shot the gap and set the guideline of a systolic reading less than 130 and a diastolic of less than 80,” Ebinger said. “And this is where some of the debate starts to come in between different types of doctors. I’m a cardiologist, and we believe lower is better. We want to push that number down as much as we can.

“Some primary care doctors and geriatricians might say, ‘You know what, that may not be the best thing for some of my patients,’ and they’re going to treat to a higher number,” he said. “So this is where clinical practice and some of the guidelines don’t always add up.”

Here are current medical guidelines, according to the US Food and Drug Administration:

  • A typical normal blood pressure is 120/80 or lower.
  • Readings between 120/80 and 129/89 are considered pre-hypertension, meaning it’s not as low as it should be but is not yet considered high blood pressure medically.
  • Blood pressure is a stage 1 red flag high if it reads 130/80.
  • Blood pressure of 140/90 or higher is considered stage 2 hypertension.

If your blood pressure reads 180/110 or higher more than once, seek out medical treatment immediately. A reading at this high level is a “hypertensive crisis,” the FDA said.

Bottom line? Take your blood pressure often (here’s how to do it right) and check in with your doctor on a regular basis.

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Health

Don’t bother with dietary supplements for heart health, study says

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CNN
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Six supplements that people commonly take for heart health don’t help lower “bad” cholesterol or improve cardiovascular health, according to a study published Sunday, but statins did.

Some people believe that common dietary supplements – fish oil, garlic, cinnamon, turmeric, plant sterols and red yeast rice – will lower their “bad” cholesterol. “Bad” cholesterol, known in the medical community as low-density lipoproteins or LDL, can cause the buildup of fatty deposits in the arteries. The fatty deposits can block the flow of oxygen and blood that the heart needs to work and the blockage can lead to a heart attack or stroke.

For this study, which was presented at the American Heart Association’s Scientific Sessions 2022 and simultaneously published in the Journal of the American College of Cardiology, researchers compared the impact of these particular supplements to the impact of a low dose of a statin – a cholesterol-lowering medication – or a placebo, which does nothing.

Researchers made this comparison in a randomized, single-blind clinical trial that involved 190 adults with no prior history of cardiovascular disease. Study participants were ages 40 to 75, and different groups got a low-dose statin called rosuvastatin, a placebo, fish oil, cinnamon, garlic, turmeric, plant sterols or red yeast rice for 28 days.

The statin had the greatest impact and significantly lowered LDL compared with the supplements and placebo.

The average LDL reduction after 28 days on a statin was nearly 40%. The statin also had the added benefit on total cholesterol, which dropped on average by 24%, and on blood triglycerides, which dropped 19%.

None of the people who took the supplements saw any significant decrease in LDL cholesterol, total cholesterol or blood triglycerides, and their results were similar to those of people who took a placebo. While there were similar adverse events in all the groups, there were a numerically higher number of problems among those who took the plant sterols or red yeast rice.

“We designed this study because many of us have had the same experience of trying to recommend evidence-based therapies that reduce cardiovascular risks to patients and then having them say ‘no thanks, I’ll just try this supplement,’ ” said study co-author Dr. Karol Watson, professor of medicine/cardiology and co-director, UCLA Program in Preventive Cardiology. “We wanted to design a very rigid, randomized, controlled trial study to prove what we already knew and show it in a rigorous way.”

Dr. Steven Nissen, a cardiologist and researcher at the Cleveland Clinic and a co-author on the study, said that patients often don’t know that dietary supplements aren’t tested in clinical trials. He calls these supplements “21st century snake oil.”

In the United States, the Dietary Supplement and Health Education Act of 1994 sharply limited the US Food and Drug Administration’s ability to regulate supplements. Unlike pharmaceutical products that have to be proven safe and effective for their intended use before a company can market them, the FDA doesn’t have to approve dietary supplements before they can be sold. It is only after they are on the market and are proven to be unsafe that the FDA can step in to regulate them.

“Patients believe studies have been done and that they are as effective as statins and can save them because they’re natural, but natural doesn’t mean safe and it doesn’t mean they’re effective,” Nissen said.

The study was funded via an unrestricted grant from AstraZeneca, which makes rosuvastatin. The company did not have any input on the methodology, data analysis and discussion of the clinical implications, according to the study.

The researchers acknowledged some limitations, including the study’s small sample size, and that its 28-study period might not capture the effect of supplements when used for a longer duration.

In a statement on Sunday, the Council for Responsible Nutrition, a trade association for the dietary supplement industry, said “supplements are not intended to replace medications or other medical treatments.”

“Dietary supplements are not intended to be quick fixes and their effects may not be revealed during the course of a study that only spans four weeks,” Andrea Wong, the group’s senior vice president for scientific and regulatory affairs, said in a statement.

Dr. James Cireddu, an invasive cardiologist and medical director of University Hospitals Harrington Heart & Vascular Institute at University Hospitals Bedford Medical Center, said the work is going to be helpful.

“They did a nice job collecting data and looking at the outcomes,” said Cireddu, who did not work on the study. “It will probably resonate with patients. I get asked about supplements all the time. I think this does a nice job of providing evidence.”

Dr. Amit Khera, chair of the AHA Scientific Sessions programming committee, did not work on the research, but said he thought this was an important study to include in the presentations this year.

“I take care of patients every day with these exact questions. Patients always ask about the supplements in lieu of or in addition to statins,” said Khera, who is a professor and director of preventive cardiology at UT Southwestern Medical Center. “I think if you have high quality evidence and a well done study it is really critical to help inform patients about the value, or in this case the lack of value, for some of these supplements for cholesterol lowering.”

Statins have been around for more than 30 years and they’ve been studied in over 170,000 people, he said. Consistently, studies show that statins lower risk.

“The good news, we know statins work,” Khera said. “That does not mean they’re perfect. That doesn’t mean everyone needs one, but for those at higher risk, we know they work and that’s well proven. If you’re going to do something different you have to make sure it works.”

With supplements, he said he often sees misinformation online.

“I think that people are always looking for something ‘natural’ but you know there’s a lot of issues with that terminology and most important we should ask do they work? That’s what this study does,” Khera adds. “It’s important to ask, are you taking something that is proven, and if you’re doing that and it’s not, is that in lieu of proven treatment. It’s a real concern.”

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Heart failure: Black patients less likely to get devices and transplants they need, study finds

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CNN
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There’s growing evidence that Black heart failure patients are less likely to get advanced therapies than White patients.

A study published Wednesday in the journal Circulation: Heart Failure finds that among a group of adults with heart failure, White people were twice as likely as Black people to receive a heart transplant or a ventricular assist device, a mechanical heart pump often used for patients with end-stage heart failure.

“The totality of the evidence suggests that we as heart failure providers are perpetuating current inequities,” Dr. Thomas Cascino, the study’s first author and a clinical instructor in the Division of Cardiovascular Disease at the University of Michigan at Ann Arbor, said in a news release. “However, recognizing disparities isn’t enough. As physicians and health care providers, we must find ways to create equitable change.”

The researchers analyzed data on 377 adults being treated for heart failure in the United States, among whom 27% identified as Black, between July 2015 and June 2016.

The data showed that a heart transplantation or a ventricular assist device was performed in 11% of the Black patients compared with 22% of the White patients, although death rates were similar in both: 18% in Black patients and 13% in White patients.

The researchers noted that patients’ preferences for ventricular assist devices, heart transplantation or other therapies did not affect the results.

“This residual inequity may be a consequence of structural racism and discrimination or provider bias impacting decision-making,” the researchers wrote.

Experts in the field say the findings offer confirmation of what doctors have been seeing for years.

“I cannot say I’m surprised,” said Dr. Jaimin Trivedi, an associate professor at the University of Louisville School of Medicine who has studied racial disparities among heart patients. He was not involved in the new research.

Trivedi’s recommendation for getting cardiovascular care is to be engaged in your own health journey. Your family or loved ones should be closely involved, too.

The new findings were also not a surprise to Dr. Dave Montgomery, a cardiologist at Piedmont Healthcare in Atlanta.

“The study confirms what has been known for too long, which is that Black heart failure patients have worse outcomes, and that part of the reason for the worse outcomes is a gradient in the quality of care they are offered,” said Montgomery, who also was not involved in the new research.

“While I am not surprised to see the results of this study, I am encouraged by the new information that it provides. These data refute the idea that disparate heart failure outcomes have to do with things like the personal preferences of the patient,” he said. “The problem is not indistinct and unapproachable, as we may have believed in the past. Instead, it shows the distinct inroad to better care for all.”

People should be educated on how to advocate for themselves and ask for options, such as the ventricular assist device, that they might not know about, said Dr. Bessie Young, an adjunct professor in health systems and population health at the University of Washington.

“There’s just difficulty for certain groups of people to get some of these really life-saving procedures and transplants, and there has to be sort of systemic changes made as to who the gatekeepers are for these devices and how people think about how patients get these devices,” Young said.

Young, a health equities researcher who was not involved in the study, believes that it shows that the disparity is caused by social determinants such as education and access, rather than biological determinants.

As for the study’s implications for health care providers, she said, “there should be equity among people who get these resources, because they’re so limited. And that’s where you have to make sure that people are looking at how they’re assessing people to get a device or transplant, making sure that they’re using some sort of equity lens to do that.”

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Paxlovid: Covid-19 treatment can interact with common heart medications, doctors warn

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CNN
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Covid-19 patients with a history of cardiovascular disease are at an increased risk of developing severe illness and could benefit most from the Covid-19 treatment Paxlovid – but there’s a catch.

Paxlovid can have dangerous interactions with some of the most common medications for cardiovascular disease, including certain statins and heart failure therapies, a new paper warns.

The review paper, published Wednesday in the Journal of the American College of Cardiology, lists dozens of cardiovascular medications and whether they are safe to give along with Paxlovid or whether they could have interactions.

Some medications such as aspirin are safe to take with Paxlovid, according to the paper, but other drugs could have interactions, and therefore, their dosage should be adjusted or temporarily discontinued while a patient is taking Paxlovid.

When President Joe Biden tested positive for Covid-19 and started Paxlovid in July, his physician Dr. Kevin O’Connor temporarily took him off Crestor and Eliquis, two heart medications that the President takes for his pre-existing conditions. Doctors say there is no short-term risk to stopping these drugs.

The review paper says that interactions between Paxlovid and certain blood thinners can cause an increased risk of bleeding. Interactions between Paxlovid and some cholesterol medications such as statins can be toxic to the liver, and interactions between Paxlovid and certain blood pressure medications could cause low blood pressure, flushing and swelling.

“There are some drugs that you simply will not be able to stop, and a doctor will have to make a decision. It’s a risk-benefit analysis,” said Dr. Jayne Morgan, a cardiologist and clinical director of the Covid Task Force at Piedmont Hospital/Healthcare in Atlanta, who was not involved in the new paper.

For cardiovascular medications that patients could discontinue in order to take Paxlovid, Morgan noted that the Covid-19 treatment is a five-day regimen.

“You’ve got to make the diagnosis and then stop your drugs and have all of that done in time to still meet that five-day window,” Morgan said, adding that people will have to consult with their doctors about what’s best for them.

The authors of the new paper – from Lahey Hospital and Medical Center, Harvard Medical School and other US institutions – wrote that Paxlovid should be avoided when potentially interacting cardiovascular medications cannot be “safely interrupted.”

Paxlovid, an oral antiviral drug, was authorized in December for the treatment of mild to moderate Covid-19 in people 12 and older who are at high risk of severe illness, hospitalization or death.

“Awareness of the presence of drug-drug interactions of Paxlovid with common cardiovascular drugs is key. System-level interventions by integrating drug-drug interactions into electronic medical records could help avoid related adverse events,” the paper’s senior author, Dr. Sarju Ganatra, director of the cardio-oncology program at Lahey Hospital and Medical Center in Massachusetts, said in a news release.

“The prescription of Paxlovid could be incorporated into an order set, which allows physicians, whether it be primary care physicians or cardiology providers, to consciously rule out any contraindications to the co-administration of Paxlovid. Consultation with other members of the health care team, particularly pharmacists, can prove to be extremely valuable,” Ganatra said. “However, a health care provider’s fundamental understanding of the drug-drug interactions with cardiovascular medications is key.”

Interactions between Paxlovid and common heart medications are well known, said Dr. Dan Barouch, director of the Center for Virology and Vaccine Research at Beth Israel Deaconess Medical Center in Boston, who was not involved in the new paper.

“Drug interactions have been reported, but I think that Paxlovid has been prescribed so widely that some doctors and patients may not be as attuned as they should be,” Barouch said.

Paxlovid is made of two antivirals, nirmatrelvir and ritonavir.

“The second drug, ritonavir, is a nonspecific drug that inhibits metabolism and increases the dose of the other drug. But the ritonavir in Paxlovid also can inhibit the metabolism of other drugs. So you have to be really careful when you prescribe Paxlovid for people who are on certain blood thinners, cardiac medications, statins and other drugs,” Barouch said. “So it’s not just a free pass.”

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Nine unusual signs a woman may be having a heart attack

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Heart disease is the number one killer of women.

I’m sure you understand chest pain signals an emergency, but did you know in men it’s a squeezing pain and in women, it may feel more like an abdominal pain — or no pain at all?

Women have more unusual signs of a heart attack than men.

Dr. Bobbi Bogaev Chapman said it might be even more overlooked if you’re in your 30s or 40s.

“There’s an implicit bias among healthcare providers that a young woman shouldn’t be having a heart attack, so they often presume the anxiety is from a panic attack and not anxiety from the inability to breathe due to fluid building up in their lungs when their heart is not working due to a heart attack,” Cardiologist Dr. Chapman explained.

Chapman said she’s had patients with symptoms as minor as indigestion and it meant they were in the middle of a heart attack.

Her advice is to listen to your instincts.

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“Listen to their gut feeling and their gut instinct,” she said. “I’ve never seen it fail a woman.”

Here are 9 unusual symptoms that can indicate the heart is in distress, according to Dr. Chapman:

1. New onset of symptoms that happen during exercise or exertion (like nausea)

2. Chest pain that comes on with exertion and goes away with rest (angina)

3. Extreme fatigue

4. Throat or jaw pain

5. Shortness of breath

6. Indigestion and heartburn

7. Gastrointestinal distress

8. Dizzy or lightheadedness

9. Nausea

Why aren’t these unusual symptoms better understood or more well-known in women?

Chapman says women are underrepresented in clinical trials.

Everyone thinks of chest pain as the main symptom because that’s what studies have told us. However, she says, those studies are mainly made up of men.

Chapman says treatments have changed and improved over the years and she favors a heart implant called Impella CP, as a device to use early in the hospital to help men and women recover faster from heart attacks and return to normal life.

“It’s a device, it’s placed in the femoral artery, it goes up and is placed inside the left ventricle of the heart and takes over the work of the heart while the patient is having a heart attack,” Chapman explained. “It decreases the pressure inside of the heart, improves the blood flow to the heart and blood flow to the rest of the body to allow that heart to rest and recover and it’s used temporarily and removed.”

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She said there has been some hesitation to use the device in women because they have smaller arteries, a decision she disagrees with since she believes use early on in a heart attack is safe and beneficial.

Most hospitals across Houston use the Impella CP, including St. Luke’s (Texas Heart Institute), Memorial Hermann, Houston Methodist, HCA, and the VA Medical Center.

Copyright 2022 by KPRC Click2Houston – All rights reserved.

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