Cardiovascular Symptoms: Is It Pregnancy or the Heart?
Melissa Perez and Afshan B. Hameed
Key Points
•Obstetric care providers should be able to differentiate common complaints of pregnancy from those of cardiovascular disease
•Cardiovascular disease typically manifests with a combination of moderate to severe symptoms, vital sign abnormalities, and/or physical examination findings
•All self-reported cardiac symptoms in a pregnant patient should be fully evaluated
•Palpitations are the most common cardiac symptom encountered during pregnancy in women with or without structural heart disease
•New-onset asthma or bilateral pulmonary infiltrates may be indicative of heart failure in pregnancy
Introduction
Cardiovascular disease (CVD) has emerged as the leading cause of maternal mortality in the United States, accounting for over one-third of all pregnancy-related deaths. A significant proportion of these deaths are preventable [1]. One of the key elements in CVD-related deaths is the inability of the health care provider to identify the presenting symptoms as markers for CVD, thus causing delays or missed diagnosis [2]. Pregnancy is a state of hemodynamic overload that may result in signs and symptoms similar to those of cardiovascular disease. It is often challenging to distinguish physiologic symptoms of pregnancy from heart disease. Common symptoms include palpitations, shortness of breath (SOB), fatigue, chest pain, and dizziness. It is imperative that the obstetrics care provider be able to differentiate benign pregnancy symptoms from those of potentially life-threatening causes. This chapter provides an overview of the common cardiovascular symptoms of pregnancy and the California Maternal Quality Care Collaborative Cardiovascular (CMQCC) disease in pregnancy toolkit designed to identify pregnant women who are at increased risk of CVD requiring further cardiovascular evaluation [3].
Basic Approach to a Symptomatic Patient
Cardiac symptoms in pregnancy and during the postpartum period, particularly if they are self-reported, require further workup. The basic systematic approach to any cardiac complaint in pregnancy follows three general principles (Figure 6.1):
1.A thorough history including the patient’s baseline exercise capacity, New York Heart Association functional status, detailed symptoms, prior cardiac history, pregnancy outcomes, and underlying medical issues.
2.Focused physical examination of the cardiovascular system.
3.Appropriate radiographic, imaging, electrocardiographic, and laboratory investigations as indicated.
If cardiac disease is high in the differential diagnosis, the goal is to refer the patient to a cardiologist for further evaluation. For the purposes of this discussion, we will focus on approach to the common cardiovascular symptoms of pregnancy.
The Cardiovascular Toolkit (CMQCC)
Maternal mortality reviews indicate that most mothers who died of CVD during pregnancy or the postpartum period had presented to the health care provider with signs and symptoms on more than one occasion that were not recognized. There is a need to maintain an index of suspicion for cardiac disease in women presenting with cardiac complaints, and to have a low threshold for further workup. The CMQCC Cardiovascular Disease in Pregnancy and Postpartum Task Force developed a toolkit that includes an overview of clinical assessment and management strategies based on risk factors and presenting signs and symptoms [3]. In this regard, it contains two algorithms designed to guide stratification and initial evaluation of symptomatic or high-risk pregnant or postpartum women (Figures 6.2 and 6.3).
Figure 6.2 Cardiovascular disease assessment in women presenting with red flags (severe signs and symptoms or personal history of CVD). (Adapted from CMQCC.com, with permission.)
Figure 6.3 Cardiovascular disease assessment in women without red flags. (Adapted from CMQCC.com, with permission.)
The first algorithm identified women who exhibit “red flags” and must get prompt evaluation and appropriate consultations. The second algorithm addresses women who are stable and without evidence of red flags or personal history of CVD. Among the 64 CVD-related maternal deaths in California between 2002–2006, the algorithms would have identified 93% of these women as high risk for CVD, with a significant potential for saving lives.
In general, global cardiovascular risk assessment should be obtained in all pregnant women, with or without symptoms (Figure 6.2). Providers can screen women any time in pregnancy, postpartum, and/or if any new or concerning symptoms arise. Providers can begin screening women at their prenatal appointments, on admission to an antepartum or postpartum unit, or for those patients who have not received care from the provider before their admission or delivery. This implementation strategy is currently underway at the University of California, Irvine and Einstein/Montefiore, Bronx, New York.
Common Cardiac Symptoms in Pregnancy
Physiologic changes in pregnancy most often lead to signs and symptoms that may mimic cardiac disease. Common complaints include nausea, fatigue, back pain, lower extremity swelling, SOB, palpitations, and chest pain (Table 6.1).
Overview of Common Symptoms in Pregnancy | ||
Symptoms | Likely Physiologic | Likely Cardiac |
Dyspnea/SOB | Gradual onset early/late third trimester Only with heavy exertion No associated symptomsa Does not interfere with activities of daily living Vital signs normal Physical examination normal CXR normal | Sudden earlier onset At rest or with mild exertion Associated symptomsa Interfere with activities of daily living Vital signs abnormal Physical examination abnormalb Infiltrates on CXR |
Palpitations | Self-limited Short duration No association with physical exertion No associated symptomsa | Persistent Longer durations Worsening with physical exertion Associated symptomsa |
Chest pain | Gastroesophageal reflux Associated with eating Resolves with antacids | Pressure-like in quality At rest or with minimal exertion abnormal ECG |
Fatigue | Gradual onset Resolves with rest Worse in third trimester No associated symptomsa | Severe Acute onset Variable timing Associated symptomsa |
Nausea | Typically in first or early second trimester No associated symptomsa | Third trimester Associated abdominal pain or other symptomsa |
Back pain | Gradual onset Worsens with advancing gestation Lower back in certain positions | Acute onset Upper back or radiates from chest |
Peripheral edema | Gradual onset Mild, improves with leg elevation Symmetric No associated symptomsa | Relatively acute onset Marked with minimal improvement with leg elevation Asymmetric Associated symptomsa |
Source: Adapted from ACOG Practice Bulletin 212, 201; CMQCC Cardiovascular disease toolkit. a Chest pain, orthopnea, paroxysmal nocturnal dyspnea, cough, fatigue, palpitations, dizziness, or syncope. b Murmur, wheezing, crackles, decreased breath sounds at lung bases, significant peripheral edema. | ||
Palpitations
Palpitations—“awareness of the heart beat”—is the most common cardiac complaint encountered in pregnancy [5]. An increase in heart rate is a normal physiologic adaptation of pregnancy [6,7]; however, palpitations may also be due to serious underlying arrhythmia and/or cardiac dysfunction [8,9]. Heart rate begins to increase as early as 5 weeks of gestation, which may be perceived as palpitations that continue throughout pregnancy. The propensity to arrhythmias in pregnancy is likely due to (i) the atrial and/or ventricular stretch caused by increased blood volume which may occur in patients with or without structural heart disease, or (ii) prolongation of QT interval by the high estrogen levels in pregnancy. Estrogen effects on cardiac arrhythmia may explain why arrhythmias are seen more frequently in females than their male counterparts [5,10]. Fortunately, most rhythm disorders seen in pregnancy are limited to sinus tachycardia or atrial/ventricular ectopic beats, both of which are considered benign. On the other hand, life-threatening arrhythmias may manifest for the first time in pregnancy [11]. Complaints of palpitations should always be taken seriously and not dismissed as a symptom of physiologic increase in heart rate. Palpitations may be the first presenting sign of a previously undiagnosed cardiac condition. The most common new-onset arrhythmia during pregnancy is supraventricular tachycardia [5,12], followed by atrial fibrillation, which may be associated valve stenosis with or without a history of rheumatic heart disease [13]. See Figure 6.4.
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