Why are so many pregnant women having heart attacks?

Incidence of acute myocardial infarction (AMI) continues to increase in women during pregnancy and the puerperium. Data from a new study published in Mayo Clinic Proceedings, point to underlying factors contributing to that trend.

The findings are from an analysis of data taken from the Agency for Healthcare Research and Quality’s Healthcare Cost and Utilizations Project National Inpatient Sample database. Women aged 18 or older who were hospitalized with AMI during pregnancy and the puerperium between January 1, 2002 and December 31, 2014 were represented in the study. 

A total of 4471 cases of AMI (8.1 [95% CI, 7.5-8.6] per 100,000 hospitalizations during pregnancy) occurred during the study period. Of these, 922 AMI cases were identified in the antepartum period, 1061 cases occurred during hospitalizations for labor and delivery, and 2390 AMI cases occurred in the postpartum period. Between 2002 and 2013, the rate of AMI that occurred in hospitalizations during pregnancy and the puerperium increased over time (from 7.1 cases per 100,000 hospitalizations during pregnancy in 2002-2003 to 9.5 cases per 100,000 hospitalizations during pregnancy in 2012-2013; P< 0.001).  

Age was found to be significantly associated with AMI risk. Women with pregnancy-related AMI were older than those without AMI (mean age, 33.1 years vs 28.0 years; P < 0.001) and were likelier to have cardiovascular comorbidities. In patients with advanced maternal age (≥ 35 years), 23.3 (95% CI, 21.1-25.6) AMI cases occurred per 100,000 hospitalizations during pregnancy. 

The proportion of AMI cases was highest among women who had any preexisting coronary artery disease (CAD) risk factors (tobacco use, hypertension, dyslipidemia, diabetes, or renal disease) when compared to patients without risk factors (66.1 vs 5.2 cases/100,000 hospitalizations during pregnancy.  Women with gestational diabetes mellitus and preeclampsia also were more likely to have AMI than women without those diagnoses (39.6 vs 7.7 and 21.0 vs. 7.5 cases/100,000 hospitalizations during pregnancy, respectively).

The study had several limitations. The trimester of pregnancy could not be determined from the data set, detailed findings from coronary angiography were not available, and in-hospital medical management was not recorded. The data also may have reflected undercoding and miscoding, and evolving treatment patterns. In addition, no information was available on fetal and newborn outcomes.

The authors believe that the trends in heart attack risk illustrated by their research point to a need for physicians to properly counsel their pregnant patients about risk factors for heart disease. That is particularly important, they said, for women who are older or who have preexisting CAD risk factors and are considering pregnancy. By working with these patients, physicians can develop a plan to monitor and control risk factors to minimize AMI risk during pregnancy. 

NEXT: Does mesh = complications in POP surgery?

Does mesh = complications in POP surgery?

Complications from use of mesh in surgery for pelvic organ prolapse (POP) have prompted action by the US Food and Drug Administration in years past and, in some cases, also lawsuits. Results of a large population-based study of POP procedures provide new insights into what factors other than the material may play a role in the adverse surgical outcomes.

Published in The Journal of Urology, the study looked at the impact of characteristics of mesh, the surgical experience, and patient selection on results of mesh-augmented POP surgery in California. Data were from the Office of Statewide Health Planning and Development on all women who underwent POP repair in the state from 2005 to 2011. 

The authors used multivariate mixed effects logistic models to explore which patient, surgical, and facility factors were associated with repeat surgery for a complication due to mesh or recurrent POP. They looked at rates of overall and mesh-related repeat surgery between patients treated with mesh-augmented and native POP repair and a concomitant incontinence repair (suburethral sling). They did that because of the potential impact of a sling on the total mesh complication rate.   

During the study period, 110,329 women had a POP repair, and in 17,873 of them (16.2%), mesh was used. In women who underwent a repair with mesh, the overall rate of repeat surgery was higher (5.4% for mesh users vs 4.3% for non-mesh; P< 0.001). But the material itself was not independently associated with repeat surgery. Rather, repair at a facility that was more likely to use mesh was independently associated with repeat surgery (highest vs lowest mesh use quartile OR 1.55, P< 0.001). Odds of repeat surgery were increased with an anterior repair (1.18, P< 0.001), apical repair (1.09, P< 0.001), and a suburethral sling (1.09, P= 0.06) whereas they were lower if the repair was posterior (0.88, P< 0.001). 

Their study, said the authors, “provides evidence against the hypothesis that mesh itself or surgical volume alone is independently responsible for mesh-based POP outcomes. Instead it provides evidence that patient selection has an important role.” They noted that the findings are limited in that they could not identify women who had undergone a procedure before the start of their study timeline or outside of California during follow up and they had no information on prolapse severity or the individual surgeons.

The results are strengthened, the researchers said, by inclusion of every surgery at nonfederal facilities in California, which is home to 14% of the entire US population. The study also included all payer types, making the results more generalizable, and used outcomes of mesh placement prior to the FDA’s 2011 statement, potentially limiting the impact of external forces such as litigation.