heart disease and the pregnant patient - oregon · pdf file · 2016-05-17heart...
TRANSCRIPT
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Heart Disease and the Pregnant
Patient
Nandita S. Scott MD, FACC
Co-Director
MGH Corrigan Women’s Heart Health Program
Cardiovascular Disease and Pregnancy Service
ACC Oregon
May 2016
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FINANCIAL DISCLOSURE:
No relevant financial relationship exists
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Causes of Pregnancy –Related Death
CDC data
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Introduction
• As maternal age advances, preexisting heart conditions more likely
• Rise in multifetal pregancies
• Increase in obesity and diabetes in population increase risk of CV
complications during pregnancy
• Patients with congenital heart disease are surviving to reproductive
age
• Childhood cancer survivors with cardiotoxic effects from therapy
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Case 1
• 42 year old for preconception counseling
• Asymptomatic, history of rheumatic mitral stenosis s/p
balloon valvuloplasty 2001
• One healthy pregnancy 2002
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Hemodynamics During Pregnancy: Heart Rate
Heart rate
Stroke volume/CO
Plasma volume
-204 8 12 16 20 24 28 32 Post-
partum
0
-10
10
20
30
40
50
% c
ha
ng
e fro
m p
re-p
reg
na
ncy v
alu
e
Duration of pregnancy (weeks)
RBC Mass
Hematocrit
Slides courtesy of Doreen Defaria Yeh
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Hemodynamics During Pregnancy: Plasma Volume
Heart rate
Stroke volume/CO
Plasma volume
-204 8 12 16 20 24 28 32 36 Post-
partum
0
-10
10
20
30
40
50
% c
ha
ng
e fro
m p
re-p
reg
na
ncy v
alu
e
Duration of pregnancy (weeks)
RBC Mass
Hematocrit
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Hemodynamics During Pregnancy: Stroke Volume
Heart rate
Stroke volume/CO
Plasma volume
-204 8 12 16 20 24 28 32 36 Post-
partum
0
-10
10
20
30
40
50
% c
ha
ng
e fro
m p
re-p
reg
na
ncy v
alu
e
Duration of pregnancy (weeks)
RBC Mass
Hematocrit
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Hemodynamics During Pregnancy: RBC Mass
Heart rate
Stroke volume/CO
Plasma volume
-204 8 12 16 20 24 28 32 36 Post-
partum
0
-10
10
20
30
40
50
% c
ha
ng
e fro
m p
re-p
reg
na
ncy v
alu
e
Duration of pregnancy (weeks)
RBC Mass
Hematocrit
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Hemodynamics During Pregnancy: Hematocrit
Heart rate
Stroke volume/CO
Plasma volume
-204 8 12 16 20 24 28 32 36 Post-
partum
0
-10
10
20
30
40
50
% c
ha
ng
e fro
m p
re-p
reg
na
ncy v
alu
e
Duration of pregnancy (weeks)
RBC Mass
Hematocrit
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Hemodynamics During Pregnancy: SVRHeart rate
Stroke volume/CO
Plasma volume
-204 8 12 16 20 24 28 32
0
-10
10
20
30
40
50
% c
ha
ng
e fro
m p
re-p
reg
na
ncy v
alu
e
Duration of pregnancy (weeks)
RBC Mass
Hematocrit
SVR
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Hemodynamics During Pregnancy: Blood Pressure
Heart rate
Stroke volume/CO
Plasma volume
-204 8 12 16 20 24 28 32 36 Post-
partum
0
-10
10
20
30
40
50
% c
ha
ng
e fro
m p
re-p
reg
na
ncy v
alu
e
Duration of pregnancy (weeks)
RBC Mass
Hematocrit
SBP
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Hankins GDV, et al. Obstet Gynecol 1985;65:139
Labor and uterine contractions: normal heart
5mmHg 20mmHg
5mmHg16mmHg
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Robson SC, Hunter S, Moore M, et al. Br J Obstet Gynae- col 1987;94(11):1037
Post delivery: Changes in hemodynamic parameters
compared with 38 weeks of gestation
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• Prospective multicenter study of pregnancy outcomes in women with heart disease
(Siu et al. Circulation 2001)
o 562 consecutive women with heart disease
o 13 Canadian centers
o 617 pregnancies
o 1994-1999
o derivation (60%) - validation (40%) model
o 74% congenital heart lesions
CARPREG – to risk stratify
pregnancies
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CARPREG: Outcomes
– Major cardiac events in 80 (13%)
• 73 of these were either CHF or arrhythmia
– 4 patients had an embolic CVA
• Dilated CMP, MVR w/suboptimal INR, MS, D-TGA s/p Mustard with low RVEF
– 3 patients died
• Mustard, Dilated CM, severe pulmonary HTN
Siu et al. Circulation 2001;104:515-521
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CARPREG risk score
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Modified WHO Classification of Maternal
Cardiovascular risk
• WHO 1 uncomplicated or mild: PS, PDA,MVPrepaired simple lesionsectopic beats
• WHO 2unoperated ASD/VSDrepaired Tetralogy of Fallotmost arrhythmias
• WHO 2-3mild LV impairment
HCMheart transplantMarfans without aortic dilatation valvular disease not in WHO 4
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Modified WHO Classification of Maternal
cardiovascular risk
• WHO 3
mechanical valve
systemic RV
post Fontan
cyanotic heart disease
other complex congenital heart disease
aortic dilatation above 40 mm in Marfans
aortic dilatation above 45 mm in BAV
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Modified WHO Classification of Maternal
Cardiovascular Risk
• WHO 4
Pulmonary artery hypertension LV EF less than 30%NYHA 3-4Previous PPCM with residual impairment Severe MSSevere symptomatic ASMarfan with root over 45 mm BAV with root over 50 mmSevere coarctation
• PREGNANCY IS CONTRA INDICATED
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Case 2
• 32 year old originally from Somalia
• Saw cardiologist in 2009 – moderate rheumatic MS/AS/AI
• ‘Reminded her that pregnancy was contra-indicated’
• Did not return until 2012 – called OB to let them know she
was 15 weeks pregnant
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For Pregnancy – two valve conditions matter
the most…..
• Mitral stenosis
• Aortic stenosis
• Valvular regurgitation is less concerning due to afterload
reduction provided by the low resistance circulation of the
placenta
• Intervene on valvular regurgitation pre conception for
symptomatic patients and valve indications for intervention
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Call from OB:
35 year old, preterm labor 30 weeks
Has emergent C section and immediately post partum, start coughing
Pulmonary edema and positive troponin
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Acute Myocardial Infarction Associated with
Pregnancy – Roth et al. JACC 2008
Literature review of 95 cases between 1995-2005
Majority of patients were over 30
1 in 16, 129 deliveries nationwide
High incidence of known risk factors
11% maternal mortality rate
9% fetal death
40% stenosis, 8% thrombus, 27% dissection, 2% spasm,
13% normal
ACE/ARBS contraindicated during pregnancy
Statins category X
Pravastatin study for preeclampsia
Cannot be on DAT prior to delivery for epidural
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Troponins
• Troponin levels have been studied during pregnancy and
are generally felt to remain in the normal range, but may
rise to the upper limit of normal
• They are higher in those with hypertensive disorders of
pregnancy, particularly pre-eclampsia.
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35 year old, 38 weeks gewstation, dyspnea
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35 year old, 38 weeks,G1P0, dyspnea, NT-proBNP691
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• Prospectively enrolled 66 women with heart disease and
12 healthy controls
• BNP at 14 +/-5 weeks antenatal
• Repeat BNP third trimester and > 6 weeks postpartum
JACC 2010
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B-Type Natriuretic Peptide in Pregnant
Women With Heart Disease
JACC Volume 56, Issue 15 2010 1247 - 1253
Adverse maternal events in 13%Peak BNP over 100 in all, predated Event in 88%
100% negative predictive value100% sensitivity70% specificity
In women with CARPREG 0 No events if BNP < 1008% if BNP over 100
In women with CARPREG 1No events if BNP < 10060% if over 100
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PeriPartum Cardiomyopathy
• Associated with
– Age
– race
– preeclampsia and hypertension
– Multiple gestations
Limited treatment data
? Prolactin mechanism, elevated sFlt1, genetics
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Peripartum Cardiomyopathy – Key Points
• 1:3000-4000 pregnancies, 1:300 Haiti
• If mother unstable – urgent delivery
• Anticoagulation for low LV EF
• Usual medical therapy for CHF except: avoid ACE/ARB
during pregnancy, ACE OK if breastfeeding
• Diuretics judiciously
• Plan vaginal delivery
• Await 6 months if possible to decide on ICD/transplant
• IPAC study: more LV systolic dysfunction in black women
and initial LV EF less than 30%, LV EDD greater than 6
cm
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Peripartum Cardiomyopathy – subsequent
pregnancies
Elkayam et al. JACC 2011
Stress echo preconception to
evaluate contractile reserve
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35 year old, G2P1
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Arrhythmias
• Most palpitations in pregnancy are benign
• Premature beats and sustained tachyarrhythmia become more
frequent or manifest for first time in pregnancy
• Studies on use of antiarrhythmics during pregnancy are limited
• Individualized decision re: risk of continuing antiarrhythmics vs.
stopping
• Postpone ablation to second trimester as high radiation
• Presence of ICD does not contraindicate future pregnancy
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Arrhythmias during Pregnancy
Slide borrowed from L. Feinberg MD
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56 year old, postmenopausal, G2P2, history
of preeclampsia, presents with chest pain
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Pre-eclampsia and Cardiovascular Outcomes
• Women with pre-eclampsia were at increased risk of developing
• HTN: (RR 3.70)
• CAD: (RR 2.16)
• CVA: (RR 1.81
• VTE(RR 1.79)
• Absolute risk that a woman with or without a history of pre-eclampsiaexperiencing one of these events at age 50 to 59 years was estimated to be 17.8 and 8.3 percent, respectively.
Bellamy L, et al. BMJ 2007
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• Women with gestational diabetes, preeclampsia or
pregnancy induced hypertension puts a woman ‘at risk’ for
CVD
• Perhaps unmask early or pre-existing endothelial
dysfunction
• Failed Stress test of Pregnancy
Circulation 2011
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Conclusion
• Cardiovascular disease is significant cause of maternal death
• Counseling and management of patients with heart disease should begin before conception
• All diseases are not created equal so evaluation of maternal risk is key
• TEAM WORK: Moderate or high risk patients require close collaboration between OB, anesthesia and cardiology
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