Pregnancy can increase the risk of morbidity and mortality in women with cardiovascular disease; however, many cardiologists are not having pre-pregnancy contraception discussions with their patients of child-bearing age. There is a need to provide evidence-based guidance for contraceptive safety and effectiveness and pregnancy planning options for this high-risk patient group, according to a paper by ACC's Cardiovascular Disease in Women Committee published April 5 in the Journal of the American College of Cardiology (JACC).

Authors of the paper said they urge women with known cardiovascular disease to develop reproductive goals that include deciding whether and when to become pregnant and encourage shared decision-making with their obstetrician, cardiologist and primary care provider to create an action plan. The paper also stresses that cardiovascular clinicians need to educate their patients about how their heart conditions impact contraceptive and medical decision-making for pregnancy.

"It is important for cardiovascular clinicians to assess for the need for contraception and appropriateness of contraceptive method both at the time of initial assessment and at subsequent annual encounters in all reproductive age women (age 15-44) with cardiovascular disease," said Kathryn J. Lindley, MD, FACC, chair of ACC's Cardiovascular Disease in Women Committee and member of the ACC's Cardio-Obstetrics Work Group, and lead author of the paper. "If a patient identified to be at increased risk for pregnancy complications is also noted to be using a contraceptive method with low effectiveness, a discussion of reproductive goals and safe and effective methods of contraception is recommended."

Another barrier to optimal care discussed in the paper are the significant disparities that exist in access to contraception and risk of unintended pregnancy among certain minority populations, including women with high cardiovascular disease burden. According to the paper, over 19 million women in the U.S., particularly in the South, Midwest and Mountain West live in "contraception deserts" and lack access to a contraceptive care facility in their county.

"Given the significant barriers to and the importance of obtaining safe and effective contraception, ensuring contraceptive access is an important part of providing comprehensive cardiovascular care," Lindley said.

Recommendations for the different types of contraception methods, which are divided into three tiers of effectiveness, are provided in the paper: Tier 1 methods (permanent sterilization and long-acting reversible contraceptives), Tier II methods (combined hormonal contraceptives, progestin-only pills and the depot medroxyprogesterone acetate injection) and Tier III methods (barrier methods, withdrawal and natural family planning).

"All clinicians, whether part of the cardio-obstetrics team or not, should be familiar with the safety, efficacy, and contraindications to contraceptive options for women with cardiovascular disease to adequately care for this population," the authors conclude.

This paper is one of a five-part JACC focus seminar series addressing a wide range of topics in the emerging cardio-obstetrics field. Other papers in the series include:

• Team-Based Care of Women With Cardiovascular Disease From Pre-Conception Through Pregnancy and Postpartum
• Management of Women With Congenital or Inherited Cardiovascular Disease From Pre-Conception Through Pregnancy and Postpartum
• Management of Women With Acquired Cardiovascular Disease From Pre-Conception Through Pregnancy and Postpartum
• Diagnostic Cardiovascular Imaging and Therapeutic Strategies in Pregnancy

Listen to the podcast by Valentin Fuster, MD, PhD MACC, editor in chief of JACC, on the series here. Also don't miss a webinar by ACC's Cardiovascular Disease in Women Committee held Sunday, April 25 at Noon ET. Learn more.

Keywords: Pregnancy, Female, Medroxyprogesterone Acetate, Progestins, Pregnancy, Unplanned, Contraceptive Agents, Natural Family Planning Methods, Obstetrics, Decision Making, Contraception, Contraceptive Devices, Family Planning Services, Pregnancy Complications, Health Services Accessibility, Primary Health Care

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