Management of Heart Failure

and Cardiomyopathies in

Pregnancy

Professor Sanjay Sharma

Disclosures: None

Cardiovascular disease in pregnancy is increasing in the Western World.

0.2-3% of all pregnancies in industrialised countries are complicated by cardiovascular disease.

Increasing prevalence of ischaemic heart disease due to advancing age of first pregnancy.

Congenital heart disease is the most frequent cardiovascular disease present during pregnancy (75-82%).

Heart failure complicates 4.6 per 100,000 pregnancies

Epidemiology of Cardiac Disease In Pregnancy

Cardiac Deaths Related to Pregnancy

2.31

Causes of Maternal Death from Cardiac Disease; UK 1994-2008

13 25%

6 15%

10 28%

8 18%

10

1

3

3

4

4

4

5

7

9

50

0 20 40 60

Other

Doxorubicin

Substance abuse

Connective tissue disease

Peripartum

HTN

HIV

Infiltrative

IHD

Myocarditis

Idiopathic

% Felker M et al NEJM 2000

Causes of Cardiomyopathy in Pregnancy

STRESSES Increased plasma volume (30-50%) Increased stroke volume Increased heart rate Increased myocardial oxygen consumption Auto-transfusion during uterine involution Hypercoagulability

Impact of the Pregnancy Related Changes in Cardiovascular Physiology in Patients with Impaired Cardiac Function

CONSEQUENCES

IMPAIRED FUNCTION

Pulmonary congestion Acute decompensated cardiac failure Arrhythmias Systemic thrombo-embolism DEATH

CARPREG Multicentre Study

562 consecutive women with heart disease

Pulmonary oedema, arrhythmia, stroke and death complicated 13% of pregnancies

Neonatal complication rate 20%

1. Prior cardiac events (heart failure, TIAs, stroke) during pregnancy) or arrhythmia

2. NYHA class > II or Cyanosis

3. Left heart obstruction:

MVA < 2 cm2,

AVA < 1.5 cm2

Aortic valve gradient > 30 mm Hg

4. Myocardial dysfunction (LVEF < 40%)

Predictors of Cardiac Risk – CARPREG Study

Score 0: Event risk 5%

Score 1: Event risk 27%

Score >1: Event risk 75%

Siu et al circulation 2001:104-515

Risk stratification and Ante-natal counselling Joint care in a multi-disciplinary setting in a specialist centre Alteration of drug therapies Requirement for anticoagulation Frequent surveillance Anticipate problems

Essentials in the Management of Women with Impaired Ventricular Function

Conditions in Which Pregnancy is Contra-indicated

‘An idiopathic cardiomyopathy presenting with heart failure secondary to left ventricular systolic dysfunction towards to the end of pregnancy or in the months following delivery. It is a diagnosis of exclusion. The LV may not be dilated but the ejection fraction is nearly always reduced below 45%.’

Peripartum Cardiomyopathy

Risk Factors for Peripartum Cardiomyopathy

Multiple Pregnancy

Pregnancy complicated by Hypertension

Multiparity Advanced

maternal age

Afro-Caribbean Race

Peripartum Cardiomyopathy

1/3000 live births May present with

acute left ventricular failure and low cardiac

output state

Diagnosis based on

echo and the absence of an

alternative cause

Rare before 36/52

More common in West Africans

? Viral myocarditis

Immune Oxidative

stress Lake salt

Selenium def

Treat with conventional heart failure therapy and

anticoagulation

50% recover 10% die within 2 years

Mortality as high as 15% in African women

0-11% require transplant

30-50% have recurrence during a subsequent

pregnancy. Advise against pregnancy in women whose LVEF has

not normalised

1. Oxygen (aim for Oxygen saturation of ≥ 95%) NIPPV with a PEEP of 5-7.5 cm H2O 2. Intravenous diuretics IV Furosemide 20-40 mg 3. Intravenous nitrates in patients with SBP > 100 mm Hg 4. Inotropic agents in those with a low output state (Dobutamine and Levosimendan) 5. Intra-aortic balloon pump counterpulsation 6. Urgent Delivery

Management of Acute Pulmonary Oedema

Therapeutic Options After Managing Acute Heart Failure

Pharmacotherapy Device Therapy LV Assistance Device Implantable cardioverter defibrillators ± Cardiac Resynchronisation therapy Transplantation

Loop diuretics

ACE inhibitors

Angiotensin II receptor blockers

Spironolactone

Beta-blockers

Digoxin

Nitrates

Hydralazine

PROGNOSTIC BENEFIT

Conventional Pharmacological Therapy

Loop diuretics

ACE inhibitors

Angiotensin II receptor blockers

Spironolactone

Beta-blockers

Digoxin

Nitrates

Hydralazine

PROGNOSTIC BENEFIT

Pharmacological Therapy During Pregnancy

Loop diuretics

ACE inhibitors

Angiotensin II receptor blockers

Spironolactone

Beta-blockers

Digoxin

Nitrates

Hydralazine

PROGNOSTIC BENEFIT

Pharmacological Therapy During Pregnancy

Pharmacological Therapy During Pregnancy

INDICATION AGENT (S)

Diuretics Pulmonary congestion Furosemide

Beta-blockers Prognostic benefit Metoprolol Bisoprolol Carvedilol

Digoxin Control AF

Mild inotropic support

Nitrates Symptomatic pulmonary congestion despite diuretic

Hydralazine

Special Precautions with Drugs

Loop Diuretic Reduce placental perfusion Beta-blockers Fetal bradycardia Intra-uterine growth retardation Apnoeic episodes Hypoglycaemia MONITOR NEWBORNS FOR 24-48 h

Indications for Anticoagulation

Intramural thrombus Systemic thromboembolism Paroxysmal or persistent AF in females with DCM Left ventricular ejection fraction < 35% Concomitant use of Bromocriptine

Anticoagulation in Heart Failure Patients

Warfarin Avoid in first trimester and last 4-8 weeks of pregnancy Maintain INR ≥ 2

Low Molecular Weight Heparin Enoxaparin and Dalteparin SC Dose adjusted Give as a twice daily regime Monitor weekly 4 h post dose Anti Xa levels (0.8-1.2)

Anticoagulation in Heart Failure Patients

Stop LMWT Heparin once contractions have started. Don’t recommence anticoagulation until all bleeding has stopped after delivery. Warfarin can be resumed after delivery. Anticoagulate for 6 months in PPCM.

Pharmacological Therapy After Delivery

ACE I Enalapril, Captopril, Bezapril Beta-blockers Bisoprolol, Metoprolol, Carvedilol Aldo antagonist Spironolactone Nitrates Hydralazine Diuretics Furosemide Digoxin Warfarin

Role of Bromocriptine

Oxidative stress Activates Cathepsin D

Cleaves Prolactin to a 16 kDa fragment

Angiostatic Pro-apoptotic

Bromocriptine prevents onset of PPCM in a mouse model

Role of Bromocriptine

Randomised pilot study within 4 weeks of delivery

Conventional therapy ± Bromocriptine 2. 5 mg twice daily for 2 weeks followed by 2.5 mg daily for another 4 weeks

Conventional therapy

LVEF recovery from 27% to 58% at 6 months post partum 1 death

LVEF recovery from 27% to 36% at 6 months post partum 4 deaths

Sliwa K Circulation 2010; 121: 1465

Dilated Cardiomyopathy

Dilated Cardiomyopathy - Management

Counselled about the risks of pregnancy. Same as conventional heart failure. Avoid ACEI, A2RB and aldosterone antagonists during pregnancy. Anticoagulation (guidelines as with PPCM) IV furosemide 20-40 mg during third stage to reduce risk of pulmonary oedema from auto-transfusion secondary to involution of the uterus.

Hypertrophic Cardiomyopathy

Pulmonary Congestion

Outflow obstruction Arrhythmias

Hypertrophic Cardiomyopathy- Management During Pregnancy

Beta-blockers when maximal wall thickness > 15 mm, LV outflow gradient > 30 mm Hg or ventricular arrhythmias. Verapamil also effective in reducing LV obstruction. Close monitoring of females with high risk profile. Anticoagulation in females with paroxysmal or persistent AF. Consider DC cardioversion in acute symptomatic AF. Cautious use of diuretics.

VASODILATATION (epidural)

BLOOD LOSS (post partum)

Pulmonary Odema

Angina

LVEDV

HYPERTOPHIC CARDIOMYOPATHY- PATHOPHYSIOLOGY DURING LABOUR

OXYTOCIN (post partum)

Hypertrophic Cardiomyopathy- Management During Labour

Aim for vaginal delivery Careful BP monitoring with epidural anaesthesia Replenish blood loss rapidly Judicious care with IV fluids Oxytocin infusion in the third stage of labour

Cardiomyopathies are amongst the commonest causes of maternal death in pregnancy in the Western World. Care should be provided in specialised joint obstetric/cardiac units.