Pregnancy & Heart Disease - Iowa ACC

HEART DISEASE IN PREGNANCY

Mahi L Ashwath MD, MBA, FACC, FASE, FSCMR

President, Iowa ACC

Associate Professor

University of Iowa Hospitals and Clinics

DISCLOSURES:

None

OUTLINE…

Review the cardiovascular changes of normal pregnancy

High risk cardiac conditions

Hypertension

Cardiomyopathy (Peripartum)

SVT and arrhythmias

Coronary artery disease

Valvular disease Stenosis

Regurgitation

Prosthetic Valves

Anticoagulation in Pregnancy

Aortic disorders and pregnancy

CARDIOVASCULAR CHANGES OF

NORMAL PREGNANCY

PREGNANCY PHYSIOLOGIC CHANGES

PREGNANCY PHYSIOLOGIC CHANGES

Elkayam et al. JACC 68,2016:396-410

CV EXAM DURING PREGNANCY

95% of pregnant patients have a systolic murmur

Loud S3 is normal

Increased volume status:

Brisk and full carotid upstroke

Displaced and enlarged apex

Varicose veins and edema

HIGH RISK CARDIAC CONDITIONS

PREPREGNANCY RISK ASSESSMENT

CARPREG

ZAHARA

WHO classification

CARPREG STUDY

ZAHARA

WHO CLASSIFICATION

IN BRIEF…

HIGH RISK CARDIAC CONDITIONS

Severe pulmonary arterial hypertension of any cause– 30-50% maternal mortality

Maternal left heart obstruction – Severe AS, Severe MS

Ventricular dysfunction – Our best medical therapy is not safe during pregnancy Class III or Class IV CHF, EF <30-40%

Prior peripartum cardiomyopathy with residual cardiomyopathy

Dilated or unstable aorta Marfan with aorta > 40-45 mm (advise against if >45 mm)

Severe cyanosis

Be careful with Mechanical valves

Moderate to severe regurgitation

HYPERTENSION IN PREGNANCY


Type Criteria

Pre – existing

Hypertension

> 140/90 mmHg, either

precedes pregnancy or <20 of

gestation

Gestational

Hypertension

>140/90 mmHg >20 weeks of

gestation

Pre Eclampsia Gestational hypertension +

proteinuria

Eclampsia Pre Eclampsia + Seizures


SBP> 170 mmHg or DBP > 110 mmHg – emergency

hospitalize

Preexisting HTN – continue same treatment, unless

the drugs are contraindicated in pregnancy

Severe - IV labetalol, Oral Methyldopa or nifedipine

IV Hydralazine is not recommended – unless other

treatments have failed

If pulmonary edema – IV Nitroglycerin

ESC Guidelines 2018. Eur Heart J 2018; 39:3165-3241

PREECLAMPSIA AND RISK OF CV DISEASE

Future risk of CV morbidity/mortality related to

severity/number of preeclampsia episodes

Early onset/severe preeclampsia

Highest risk of preterm delivery

8-9 fold risk of cardiovascular death

Mild late preeclampsia

no associated future cardiovascular disease

CARDIOMYOPATHY AND THE HEART

PERIPARTUM CARDIOMYOPATHY

NEJM 312;1432, 1985

PERIPARTUM CARDIOMYOPATHY

New diagnosis of Heart Failure due to LV dysfunction –

last trimester to first 6 months post partum

Increase in frequency

Age > 30 year

Multifetal pregnancy

Multiparity

Tocolytic

Black

HTN, DM, smoking

MANAGEMENT

Standard Heart Failure Treatment No ACEI or ARB or Aldosterone antagonists or ARNI or Atenolol

Can use Digoxin, Hydralazine, Beta blockers

Diuretics if needed

Bromocriptine – blocks prolactin release Increase in EF with improved outcome versus standard Rx

2.5 mg bid for 2 weeks, 2.5 mg daily for 6 weeks with HF therapy

Not much used in US

Anticoagulation for EF <35%, or bromocriptine

Continue Rx for 1 year and reassess

Life long follow up

PROGNOSIS

Multicenter Investigations of Pregnancy Associated Cardiomyopathy (IPAC) study 13% had major events or persistent severe decrease in

LVEF

Poor prognosis LVEF <30%

EDD >60mm

Subsequent Pregnancy: CHF in 21% normal EF and 44% reduced EF

Death – 10% normal EF and 19% reduced EF pts

Advise against pregnancy

EF <25% at presentation

Persistent decrease in EF

McNamara D et al: JACC 2015

PROGNOSIS

McNamara D et al: JACC 2015

ESC Guidelines 2018. Eur Heart J 2018; 39:3165-3241

ARRHYTHMIAS - SVT

SVT MANAGEMENT

Acute

Awake, alert patient - IV Adenosine

Hemodynamically unstable – DC Cardioversion

Recurrent SVT

Beta-blocker

Calcium channel blocker

Sotalol

Flecainide

Amiodarone-contraindicated by manufacturer

Monitor neonatal EKG and thyroid

Excreted in breast milk

Ablation

CORONARY ARTERY DISEASE

CORONARY ARTERY DISEASE

Mortality 7%

Treatment-

Initial-heparin, aspirin, beta-blocker, nitrate

Nitrates excreted in breast milk-possible fetal methemoglobinemia

Statins not recommended

Clopidogrel, GP IIb IIIa inhibitors, DOACs - Safety not established

PCI with bare metal stent

Thrombolytics if cath/PCI not available

Exclude spontaneous coronary artery dissection and aortic dissection

SPONTANEOUS CORONARY ARTERY DISSECTION

Most common cause of pregnancy associated MI

(43%)

Most frequent during late pregnancy / early

postpartum

Pregnant SCAD patients

More acute presentations and high-risk features

Mostly left sided vessels or multivessel disease

VALVULAR HEART DISEASE

MITRAL STENOSIS AND PREGNANCY

Poorly tolerated Tachycardia,

Increased plasma volume

Maternal Risks- Heart failure - Pulmonary edema in II & III trimester,

Atrial fibrillation

Fetal risks- Prematurity 20-30%;

IUGR 5-20%

Moderate & severe MS counseled against pregnancy

without prior intervention

• Pharmacological Management – Restrict activity

– Beta blockers

– Diuretics as needed

• NYHA III/ IV or PASP >50 mmHg – Balloon Mitral Valvotomy

• Anticoagulation – Atrial fibrillation, LA thrombus, LA smoke, Dilated LA

• Delivery – Vaginal – Mild MS, Class I/II, no PAH

– CS – Mod to Sev MS, Anticoagulation, Class III/ IV, PAH

MITRAL STENOSIS AND PREGNANCY

AORTIC STENOSIS

• Unable to augment Cardiac Output – Preload and Hypotension Sensitive

• Maternal – Heart failure

• Fetal – Decreased placental perfusion

– IUGR

– Preterm Labor

• Pharmacological Management

– Restrict activity

– Beta blockers

– Diuretics as needed

• Severe symptomatic Aortic stenosis,

– Consider Balloon Aortic Valvotomy/ Emergency AVR.

• Delivery

– Vaginal – Mild MS, Class I/II, no PAH

– CS – Mod to Sev MS, Anticoagulation, Class III/ IV, PAH

AORTIC STENOSIS

REGURGITANT LESIONS

Better tolerated

Maternal risk- HF,

Arrhythmias,

Progressive worsening of regurgitations

Moderate to severe regurgitant lesions – exercise testing to decide pre pregnancy intervention

Severe lesions + symptoms/ impaired LV function/

Ventricular dilatation treated surgically, if possible repair

PROSTHETIC VALVES

TISSUE PROSTHESIS

Increased degeneration

in young

Reoperation risk

Possible accelerated

degeneration in

pregnancy

MECHANICAL PROSTHESIS

Prepregnancy

counseling,

centralization of care

critical

Anticoagulation

management during

pregnancy and delivery

ANTICOAGULATION IN PREGNANCY


Hematologic changes

Increased clotting factor concentration

Increased platelet adhesiveness

Decreased fibrinolysis and protein S activity

Increased risk of thrombosis and embolization

WARFARIN IN PREGNANCY

Low molecular weight-crosses placenta

Increased risk of fetal loss, prematurity,

stillbirth, fetal intracranial hemorrhage,

retroplacental hemorrhage

Embryopathy risk-exposure 6-12 weeks

Safe to use greater than 5 mg per day after

12 weeks

UNFRACTIONATED HEPARIN

Increased molecular weight-does not cross

placenta

Treatment of choice-late pregnancy, delivery

Long-term-osteoporosis-30%, steroidal

abscesses, decreased platelets, alopecia

Vitale N et al: JACC 1999

LMWH IN PREGNANCY

Does not cross the placenta

No teratogenic effects

Potential advantages

Increased bioavailability, administration ease

Decreased osteoporosis and thrombocytopenia


ACC/ AHA VHD Guidelines 2014


Halpern et al. JACC 2019


Low-dose aspirin

Safe-antithrombotic effect not proven

Used in shunts, cyanosis, bioprosthesis

Possible decreased incidence of preeclampsia

Thrombolytic therapy

Emergency use only

Thrombin inhibitor/DOAC

No safety data

IE PROPHYLAXIS IN PREGNANCY

Not required during uncomplicated delivery

Reasonable to administer in high-risk patients

AORTIC DISORDERS AND PREGNANCY

PREGNANCY IN MARFAN, BICUSPID, EDS

Preexisting medial changes

Hemodynamic changes of

pregnancy

Risk of

Dissection, rupture

European Heart Journal 2018 39:3165-3241

AORTIC DISORDERS AND PREGNANCY

Aorta imaging

Aorta > 45 mm – no pregnancy

Aorta < 40 mm – reasonable if low risk

Aorta 40-45 mm – individualize – family hx, rate of

aortic dilation

Genetics, prenatal diagnosis – Fetal

inheritance


ESC GUIDELINES 2018


RECOMMENDATIONS

During pregnancy

Beta blocker (even if aorta is normal size) regular aorta imaging (every 4-6 weeks)

Fetal echo

Peripartum

Facilitated vaginal delivery

C – section for Ao >40 mm or increase in size

IE prophylaxis

Postpartum

Dissection risk persists (highest risk upto 4-6 weeks after pregnancy)

ACUTE PERICARDITIS IN PREGNANCY

Not much data

High risk features – hospitalize

Anticoagulation, immunosuppressed, fever,

trauma, tamponade, large effusion,

myopericarditis

Management

<20 weeks – NSAIDs

>20 weeks – corticosteroid

Colchicine is contraindicated in Pregnancy

CARDIAC DRUGS IN PREGNANCY

MEDICAL THERAPIES AND PREGNANCY

Halpern et al. JACC 2019

RADIATION AND PREGNANCY

MRI DURING PREGNANCY

MRI is safe

Gadolinium crosses placenta – small molecule

– repeated swallowing by the fetus – unclear

risk

SUMMARY

Review the cardiovascular changes of normal pregnancy

High risk cardiac conditions

Hypertension

Cardiomyopathy (Peripartum)

SVT and arrhythmias

Coronary artery disease

Valvular disease

Stenosis

Regurgitation

Prosthetic Valves

Anticoagulation and Drugs in Pregnancy

Aortic disorders and pregnancy

Severe pulmonary arterial hypertension

Maternal left heart obstruction

Ventricular dysfunction

Dilated or unstable aorta

Severe cyanosis

CONTRAINDICATIONS TO PREGNANCY

Elkayam, U. et al. J Am Coll Cardiol. 2016;68(4):396–410.

Thank You!!!

Pregnancy & Heart Disease - Iowa ACC

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