Management of Heart Failure and Cardiomyopathies in Pregnancy

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1 Management of Heart Failure and Cardiomyopathies in Pregnancy Professor Sanjay Sharma Disclosures: None

2 Epidemiology of Cardiac Disease In Pregnancy Cardiovascular disease in pregnancy is increasing in the Western World % 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

3 Cardiac Deaths Related to Pregnancy 2.31

4 Causes of Maternal Death from Cardiac Disease; UK % 10 28% 8 18% 13 25%

5 Causes of Cardiomyopathy in Pregnancy Idiopathic Myocarditis IHD Infiltrative HIV HTN Peripartum Connective tissue disease Substance abuse Doxorubicin Other % Felker M et al NEJM 2000

6 Impact of the Pregnancy Related Changes in Cardiovascular Physiology in Patients with Impaired Cardiac Function STRESSES Increased plasma volume (30-50%) Increased stroke volume Increased heart rate Increased myocardial oxygen consumption Auto-transfusion during uterine involution Hypercoagulability IMPAIRED FUNCTION CONSEQUENCES Pulmonary congestion Acute decompensated cardiac failure Arrhythmias Systemic thromboembolism DEATH

7 CARPREG Multicentre Study 562 consecutive women with heart disease Pulmonary oedema, arrhythmia, stroke and death complicated 13% of pregnancies Neonatal complication rate 20%

8 Predictors of Cardiac Risk CARPREG Study 1. Prior cardiac events (heart failure, TIAs, stroke) during pregnancy) or arrhythmia 2. NYHA class > II or Cyanosis 3. Left heart obstruction: MVA < 2 cm 2, AVA < 1.5 cm 2 Aortic valve gradient > 30 mm Hg 4. Myocardial dysfunction (LVEF < 40%) Siu et al circulation 2001: Score 0: Event risk 5% Score 1: Event risk 27% Score >1: Event risk 75%

9 Essentials in the Management of Women with Impaired Ventricular Function 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

10 Conditions in Which Pregnancy is Contra-indicated

11 Peripartum Cardiomyopathy 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%.

12 Risk Factors for Peripartum Cardiomyopathy Multiple Pregnancy Afro-Caribbean Race Pregnancy complicated by Hypertension Advanced maternal age Multiparity

13 More common in West Africans? Viral myocarditis Immune Oxidative stress Lake salt Selenium def 30-50% have recurrence during a subsequent pregnancy. Advise against pregnancy in women whose LVEF has not normalised 1/3000 live births Peripartum Cardiomyopathy 50% recover 10% die within 2 years Mortality as high as 15% in African women 0-11% require transplant 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 Treat with conventional heart failure therapy and anticoagulation

14 Management of Acute Pulmonary Oedema 1. Oxygen (aim for Oxygen saturation of 95%) NIPPV with a PEEP of cm H 2 O 2. Intravenous diuretics IV Furosemide 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

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16 Therapeutic Options After Managing Acute Heart Failure Pharmacotherapy Device Therapy LV Assistance Device Implantable cardioverter defibrillators ± Cardiac Resynchronisation therapy Transplantation

17 Conventional Pharmacological Therapy Loop diuretics ACE inhibitors Angiotensin II receptor blockers Spironolactone Beta-blockers Digoxin Nitrates Hydralazine PROGNOSTIC BENEFIT

18 Pharmacological Therapy During Pregnancy Loop diuretics ACE inhibitors Angiotensin II receptor blockers Spironolactone Beta-blockers Digoxin Nitrates Hydralazine PROGNOSTIC BENEFIT

19 Pharmacological Therapy During Pregnancy Loop diuretics ACE inhibitors Angiotensin II receptor blockers Spironolactone Beta-blockers Digoxin Nitrates Hydralazine PROGNOSTIC BENEFIT

20 Pharmacological Therapy During Pregnancy INDICATION AGENT (S) Diuretics Pulmonary congestion Furosemide Beta-blockers Prognostic benefit Metoprolol Bisoprolol Carvedilol Digoxin Nitrates Hydralazine Control AF Mild inotropic support Symptomatic pulmonary congestion despite diuretic

21 Special Precautions with Drugs Loop Diuretic Reduce placental perfusion Beta-blockers Fetal bradycardia Intra-uterine growth retardation Apnoeic episodes Hypoglycaemia MONITOR NEWBORNS FOR h

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

23 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 ( )

24 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.

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

26 Role of Bromocriptine Oxidative stress Activates Cathepsin D Bromocriptine prevents onset of PPCM in a mouse model Cleaves Prolactin to a 16 kda fragment Angiostatic Pro-apoptotic

27 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 Sliwa K Circulation 2010; 121: 1465 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

28 Dilated Cardiomyopathy

29 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 mg during third stage to reduce risk of pulmonary oedema from auto-transfusion secondary to involution of the uterus.

30 Hypertrophic Cardiomyopathy

31 Pulmonary Congestion Outflow obstruction Arrhythmias

32 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.

33 HYPERTOPHIC CARDIOMYOPATHY- PATHOPHYSIOLOGY DURING LABOUR VASODILATATION (epidural) BLOOD LOSS (post partum) OXYTOCIN (post partum) LVEDV Pulmonary Odema Angina

34 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

35 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.