One Heart Beating for Two As if they didnít have enough to worry about, some women with heart disease have to deal with another concern that doesnít affect men: pregnancy. Especially as more women become pregnant well into their 40s, some of them will find that as theyíre trying to have a child, theyíll also be trying to manage cardiovascular problems, such as coronary artery disease or hypertension. Itís a delicate balanceóone that canít always be maintained. ìAs pregnancies are occurring more often in the later stages of life, weíre seeing more pregnant women either with coronary disease thatís pre-existing, or that develops as a complication of pregnancy,î said Dr. Joseph Navarijo, a cardiologist and clinical instructor in cardiology at St. Lukeís Episcopal Hospital in Houston. In fact, between 1 percent and 4 percent of pregnant women who do not have cardiac conditions when they become pregnant will develop them over the course of their pregnancies. Practicing medicine at a tertiary care hospital with a high-risk pregnancy department, Dr. Navarijo has developed a specialty in pregnancy that is complicated by heart disease. Pregnancy puts tremendous strains on the heart and circulatory system. A womanís blood volume can increase by up to 50 percent over the course of a pregna ncy, requiring the heart to work that much harder just to move the blood around. If there is an existing coronary disease, an already-overextended heart can be pushed beyond its limits. Adding to the complications is the fact that many of the traditional drugs used to manage heart disease must be discontinued when a woman is pregnant. ìYou need to consider the risks not only to the woman but also to the fetus,î said Navarijo. ìStatin drugs have not been studied appropriately during pregnancy, so these will have to be eliminated, as will some blood thinners, because of their teratogenic [fetal-defect causing] effects.î Also on the ìnoî list of common cardiac medications are ACE (angiotensin-converting enzyme) inhibitors, which can cause a number of complications to the fetus. ìBeta blockers, however, are considered relatively safe during pregnancy, so we can use those to reduce the burden of the increased volume to the heart,î Navarijo said. However, beta blockers may not be completely without potential complications, so patients may have to abandon them if problems develop. In some cases, said Navarijo, a woman with particularly severe cardiac problems will be advised not to become pregnant. ìOften times, weíll make recommendations based on a percentage risk calculated using whatís called an ejection fraction, a measure of the heart function. Itís a gross estimation but still a reliable one of the patientís risk of developing complications,î he explained. Additional complicating conditions, such as diabetes, are factored into the advice Navarijo gives to each patient. ìIf a patient has heart disease with a low ejection fraction and associated diabetes, I would tend to recommend not pursuing pregnancy,î he said. ìIf women who are at particularly high risk donít heed those warnings and do become pregnant, sometimes we fortunately have a very successful pregnancy, other times complications can lead to both the loss of the pregnancy and the death of the woman herself.î The bottom line for pregnant women with heart disease, said Navarijo, is close clinical monitoring. ìWe have to see these patients much more frequently and keep constant watch on the ischemic burden to the heart. Itís very hands on, and thereís no easy way to handle it. Itís very important for a woman in this situation to receive specialized medical care.î óGina Shaw