AHA Statement Addresses ACS Management Gap in Younger Women

Although acute coronary syndromes are relatively uncommon among premenopausal women, a new scientific statement from the American Heart Association (AHA) urges physicians to be aware of a variety of causes and some special considerations in the diagnosis and treatment of these high-risk patients.

Noting the poorer outcomes that are often seen in young patients, the writing committee, led by Jason C. Kovacic, MBBS, PhD (Victor Chang Cardiac Research Institute, Darlinghurst, Australia), points to a lack of robust clinical trial data. This absence of evidence may make clinicians less certain about how to proceed in this population, they say. The statement is an attempt to fill gaps in the diagnosis and management of premenopausal women presenting with ACS given the lack of integrated management pathways.

The authors propose one algorithm to determine whether a premenopausal woman with ACS should undergo invasive coronary angiography or coronary CT angiography, as well as another that provides a detailed approach to imaging and treatment of spontaneous coronary artery dissection (SCAD). Myocardial infarction with nonobstructive coronary arteries (MINOCA) also receives special attention in the paper.

“When considering ACS in a premenopausal woman, we need to keep in mind that while atherosclerosis with obstructive coronary arteries remains the most common cause, other presentations including SCAD, MINOCA, and coronary spasm occur frequently,” vice chair Harmony R. Reynolds, MD (New York University Langone Heart), told TCTMD in an email. “Our diagnostic algorithms and therapeutic approaches need to keep this broader differential diagnosis in mind.

“We also need to make sure that we provide the highest quality of comprehensive care for young women, from admission to postdischarge cardiac rehabilitation,” she stressed.

The scientific statement was published last week in Circulation.

Special Considerations in Younger Patients

An early invasive strategy may be necessary in some high-risk women, and invasive testing may be the primary avenue for establishing a diagnosis, especially if CAD is not present or is mild. In addition to aggressive management of risk factors, the committee encourages referral or transfer to a specialized center if establishing a causal diagnosis proves difficult in premenopausal women.

Given their age, many of these patients may be pregnant. One section of the document addresses when and how to consider angiography and revascularization in a pregnant patient, including how to reduce radiation-exposure risks in the cath lab and the specialized medication safety issues for both the mother and fetus.

The AHA document also addresses concerns in women who have ACS and are actively breastfeeding. Early resumption of breastfeeding after angiography is generally recommended, “assuming that the patient is hemodynamically stable and there are no medical con­traindications,” it explains. Given the importance of balancing maternal risk with infant exposure, the recommendations also stress that shared decision-making for breastfeeding mothers is critical.

“These should be helpful to physicians and hopefully will lead to more routine invasive care for these high-risk ACS patients,” Reynolds noted.

Importantly, too, the statement includes a discussion of the importance of cardiac rehab. In a separate scientific statement published recently, the AHA notes that fewer than one in five eligible women participate in cardiac rehab and suggests that removing the human element from the equation, thereby making cardiac rehab an “opt out” system, may lift barriers for some women, including younger women where there’s a perception they don’t need it.

Other special considerations for managing ACS in premenopausal that are addressed in the document include contraceptive counseling; migraine headaches; referral for genetic evaluation for conditions such as familial hypercholesterolemia or monogenic arteriopathies associated with SCAD; managing post ACS depression and anxiety; and additional surveillance recommendations such as vascular screening and screening for fibromuscular dysplasia (FMD), a non-inflammatory, non-atherosclerotic vascular disease.

Of the proposed future research directions, Reynolds would like to see efforts address how best to monitor young women with post-ACS chest pain and further evaluation of secondary preventive therapies after SCAD and MINOCA. Finally, she’d like to understand the best way to increase referrals and completion of cardiac rehab in young women with ACS, including tailoring to the needs and preferences of young women.