The Women and Arrhythmias Program, newly established at Brigham and Women’s Hospital (BWH), offers evaluation and management for women with cardiac arrhythmias. The incidence and etiology of arrhythmias can be different for women, and women may require special consideration regarding therapy. Program Director Usha B. Tedrow, MD, says, “These unique aspects, which are critical to successful evaluation and management of women’s arrhythmias, are often overlooked.”
Diagnosis
Delayed or missed diagnosis can be a significant problem for women with arrhythmias, since some symptoms can be mistaken for other conditions, including panic, stress, and anxiety and are not evaluated as cardiac problems. In addition, the frequency of some arrhythmias can be hormonally related and can be more evident in particular phases of the menstrual cycle, and are therefore more difficult to evaluate. Women referred to the Women and Arrhythmias Program are evaluated through careful history and physical examination, echocardiography, exercise testing, and portable monitors to document heart rhythms. This information helps physicians tailor the most beneficial treatment strategy for each patient.
Indications for referral
Women who may benefit from the services of the Women and Arrhythmias Program include:
- Women with symptoms of or risk factors for cardiac arrhythmias;
- Women with difficult-to-manage arrhythmias;
- Women with history of arrhythmias who are considering pregnancy.
Treatment considerations
Gender-related differences in arrhythmias have profound implications for treatment.
Long QT syndrome
Women are more likely than men to be seriously affected by either congenital or acquired QT prolongation, and physicians must therefore be very cautious when prescribing any drug – including antibacterials, antifungals, antidepressants, and antiarrhythmics – that have QT prolongation as a side-effect.
Ventricular arrhythmias
Evaluation and management of ventricular arrhythmias is more complex in women than in men. These disturbances in men are more likely to be a result of coronary artery disease, whereas in women, traditionally less common causes must be considered more frequently, including syndromes associated with valvular heart disease and nonischemic cardiomyopathies.
Pregnancy
Pregnancy and the peripartum period present special challenges for managing women with arrhythmias. Women may or may not be able to continue their medications during pregnancy, and they may wish to consider catheter ablation before becoming pregnant so they can get off their medications altogether. Many of the arrhythmias that afflict women – atrial tachycardia, idiopathic ventricular tachycardia, and AV node reentrant tachycardia – are quite amenable to catheter treatment, with success rates approaching 95 percent. New onset symptoms such as palpitations and lightheadedness during pregnancy should be evaluated for arrhythmias and the patient should be evaluated for any potential weakening of the heart muscle during pregnancy. Also, women with chronic long QT syndrome are likely to experience hormonally-driven fluctuations in symptoms and are therefore at elevated risk for adverse events, including sudden death – during this period.
Dr. Tedrow says, “It is very important for clinicians who care for women with known or suspected arrhythmias to be aware of the gender differences in prevalence, risk stratification, and treatment response and to customize their treatment accordingly.”
Multidisciplinary care
Patients with identified arrhythmias may benefit from medical therapy – beta-blockers, calcium channel blockers and anti-arrhythmics – as well as all the cutting-edge services of BWH’s Electrophysiology Laboratory – catheter ablation, pacemaker or defibrillator placement, and cardiac resynchronization. In addition patients benefit from the multispecialty expertise available in BWH’s cardiovascular, heart failure, and interventional cardiology programs.
Research
Dr. Tedrow and her colleague Dr. Robert Eckart have recently completed a study of the incidence of sudden cardiac death in female military recruits that will be presented at the American Heart Association meetings in November. In addition, Dr. Tedrow is engaged in research designed to investigate the physiologic implications of pacing from pacemakers and defibrillators on the heart and how to optimize therapy for the 30 percent of patients whose heart failure does not improve after cardiac resynchronization.
Future
On the near horizon, a number of emerging developments will benefit both men and women with cardiac arrhythmias.
- Advances in catheter ablation techniques for atrial fibrillation, currently the first chance for a cure for this arrhythmia, will continue to proceed, leading to shorter procedure times and decreased risk for patients.
- Smaller implantable cardiac devices, especially defibrillators and smaller-caliber leads will make these therapies more available to smaller women.
- Merged imaging technology will allow physicians to see electrophysiology data superimposed over anatomic images, affording physicians a better understanding of individual arrhythmia physiology and symptoms.
It is anticipated that this technology will be available in BWH’s “operating room of the future” that will incorporate multiple imaging modalities such as PET, CT, and MRI into a procedure room. Ablations and other procedures will for the first time be able to be performed in an integrated fashion with these imaging modalities.
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