Interview with Prof. Athena Poppas: Women's cardiovascular disease in the treatment and research need to pay attention to things

 

  Editor Note：At the Great Wall Cardiology Congress 2020 (GW-ICC 2020), Prof. Athena Poppas, President of the American College of Cardiology (ACC), Director of the Department of Cardiology, Miriam and Newport Hospitals, was invited to discuss topics and research experiences in the treatment of cardiovascular diseases in women at the International Partnership Forum.
  After the meeting, Professor Poppas was interviewed by International Circulation and shared her therapeutic and research ideas in this field.

  Now organize as follows, in order to offer readers.

IC: Pregnant women with cardiovascular disease pose a huge challenge to cardiovascular doctors and obstetricians. Would you please share us how women with cardiovascular disease conduct risk assessment before pregnancy?

 Dr Poppas: It’s a very good question, because one of the most important things in having a safe pregnancy when you have cardiovascular disease, is a very thorough assessment, not only of the structure (so we are clear what the actual cardiac problem is), but the function of the patient as well, both objective and subjective assessments. That will help assess the risk, and also allow us to optimize them, or treat them if they need any surgical or percutaneous treatment. We need to make sure they are seen, they have a discussion and a physical examination. They may need imaging, such as an echo or MRI to further ascertain the issue, particularly for complex congenital disease. And not only subjectively what New York Heart Association (NYHA) functional class they are in, which predicts risk, but sometimes, with a coronary patient for example, you may want to do a stress test to assess if they have any ischemia.

IC:  Pregnant women with cardiovascular disease have an increased risk of death and heart failure. What is the recommended treatment strategy for these patients in the relevant guidelines?

 Dr Poppas: Excellent question again. It depends on the actual problem. For example, in valvular heart disease, if there is a normal ventricle and normal functional status, these patients tend to do well. That volume lesion is well tolerated. On the other hand, stenotic lesions, such as mitral stenosis and aortic stenosis, may be well tolerated, if they don’t have pulmonary hypertension and their ventricles are normal, unless it is severe or symptomatic. Then, the risks of heart failure go up. So assessing for those prior in the complex congenital patients is important. That’s a very long list. We usually look at the modified World Health Organization classification – I, II, III and IV – as per the European Guidelines. For example, those who are in Class IV in the World Health Organization classification have a very high risk of birth mortality and morbidity. For example, in Eisenmenger’s syndrome and severe pulmonary hypertension, you would counsel against pregnancy, or recommend termination should they become pregnant.

IC:  What are the characteristics of heart failure with preserved ejection fraction in women? What are the common clinical treatment strategies?

 Dr Poppas: For even non-pregnant women in general, that is a good point. Heart failure with preserved ejection fraction is quite common, particularly in the elderly. Up to 50% of women who have heart failure, have it due to preserved ejection fraction rather than reduced ejection fraction, due to a number of confounding factors. Maybe that is because of more hypertension and more risk factors, but also because they tend to live longer and it occurs in the elderly. The treatment strategies should not differ between men and women. We haven’t found a medication that changes mortality per se, as we have with reduced ejection fraction for either gender. We need to be careful to assess functional capacity, because the primary problem with these patients is that they are on the steep part of the pressure-volume curve, so their pulmonary pressures and their dyspnea become markedly worse with a little bit of exercise.

IC:  What are the characteristics of the gender differences in the short-term and long-term prognosis of heart failure?

Dr Poppas: Again, it usually depends on the etiology. We know that women with coronary disease tend to present later. They tend to present with more comorbidity. When we look at or adjust for both age and comorbidity, there doesn’t appear to be a gender difference, but that does mean that women in general tend to have more comorbidity that needs to be taken care of. There does seem to be some gender difference around heart failure in particular. We don’t have as many women included in the heart failure trials to look at sub-analyses per se, but importantly, we are still not treating women any differently. For example, with ARNI or ICDs, we still use the same criteria for men and women. I think that is an important take-home message. We didn’t do a good enough job of recruiting women into trials, so without further data, we treat them following the same guidelines.