Catherine Nelson-Piercy. Guy s & St Thomas Hospitals & Queen Charlotte s Hospital London, UK

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1 Cardiac Disease and Pregnancy Catherine Nelson-Piercy Guy s & St Thomas Hospitals & Queen Charlotte s Hospital London, UK

2 Physiological changes in pregnancy Cardiac Output (CO) increases by 40% Further increases peripartum Stroke Volume and Heart Rate increase Peripheral vasodilation and decrease SVR PCWP and CVP unaltered Colloid osmotic pressure reduced Supine position = 25% fall in CO

3 Physiological Changes in Pregnancy Early peak in HR (17%) SV (17%) CO (45%) Plasma volume (40-50%) Heart rate Non pregnant weeks gestation Slide courtesy of Sara Thorne Post delivery Cardiac output & Stroke volume

4 Cardiac disease Other Indirect* causes Indirect neurological conditions* Sepsis Pre-eclampsia and eclampsia Thrombosis and thromboembolism Amniotic fluid embolism Psychiatric causes Early pregnancy deaths Haemorrhage Anaesthesia Other Direct** Indirect malignancies Rate per 100,000 maternities Leading causes of maternal deaths , UK DIRECT INDIRECT Saving Mothers Lives , National launch - March 2011

5 Cardiac Deaths 2.5 Rates per million maternities Saving Mothers Lives , National launch - March 2011

6 Cardiac deaths; UK Type and cause of death Acquired Aortic dissection Myocardial infarction (MI) Ischaemic heart disease (No MI) Sudden Adult Death Syndrome (SADS) Peripartum cardiomyopathy 4 0* 9** Other Cardiomyopathy Myocarditis or myocardial fibrosis Mitral stenosis or valve disease Thrombosed aortic or tricuspid valve Infective endocarditis Right or Left ventricular hypertrophy or hypertensive heart disease Congenital Pulmonary hypertension (PHT) Congenital heart disease (not PHT or thrombosed aortic valve) Other Total 44 48*** 53 *12 Late cases reported in **2 late cases reported in ***includes one women for whom little information on cause was available Saving Mothers Lives , National launch - March 2011

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8 MI / Ischaemic heart disease (2003-8) Total UKOSS* MI (14 angio) Atheroma (61%) 7 (50%) Dissection (11%) 3 (21%) Embolus/thrombosis Normal Coronaries 2 Undetermined IHD without MI Total IHD Total MI / IHD 16 11** 27 *antenatal MI, ** 9 died postnatally Saving Mothers Lives , National launch - March 2011

9 Risk factors for IHD Aged (av 35 years) 6 35 yrs old 11 parous 6 obese, (4 BMI > 40) 7 smoked 2 hypertension 1 FH +ve 2 type 2 diabetes 3 asian Aged 28 to 46 (av 36 years) 8/11 35 yrs old (5 40) All were parous, (7 para 4) 3 were obese 6 smoked 4 hypertension 2 FH +ve 1 GDM 1 hypercholesterolaemia 1 sickle cell disease

10 Death rates per 100,000 population from myocardial infarction among women of childbearing age, UK, Deaths in women in UK from Acute Myocardial Infarction AGE in years percentage of maternities in the UK Age ONS, General Register Office Scotland, General Register Office, Northern Ireland

11 IHD in pregnancy: messages High index of suspicion in those with risk factors May not present with typical angina Myocardial infarction and acute coronary syndrome can present with atypical features in pregnancy such as abdominal or epigastric pain and vomiting or dizziness. ECG and troponin unchanged by pregnancy single normal ECG does not exclude ischaemia, especially if performed when the woman is pain-free. Get them to the catheter lab quickly Thrombolysis safe Use bare metal stents Aspirin and Clopidogrel are safe

12 Peripartum Cardiomyopathy Heart Failure Association of the European Society of cardiology Working Group on PPCM 2010 PPCM is an idiopathic cardiomyopathy presenting with heart failure secondary to LV systolic dysfunction toward the end of pregnancy or in the months following delivery, where no other cause of heart failure is found. It is a diagnosis of exclusion. The left ventricle may not be dilated but the ejection fraction is nearly always reduced below 45%. Sliwa K, Hilfiker-Kleiner D, Petrie MC, et al. Eur J Heart Fail 2010;12:

13 Risk factors Multiple pregnancy Pregnancy complicated by hypertension (pre-existing or preeclampsia) Multiparity Advanced maternal age Afro-Carribean race Diagnosis Echocardiography. Diagnostic criteria Left ventricular ejection fraction < 45% (LVEF at presentation 26-31%) Heart enlarged with global dilation of all four chambers and markedly reduced left ventricular function

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15 The STAT3 oxidative stress cathepsin D 16 kda cascade. Yamac H et al. Heart 2010;96: by BMJ Publishing Group Ltd and British Cardiovascular Society

16 Management Elective delivery if antenatal. Thromboprophylaxis. Conventional treatment for heart failure diuretics, vasodilators (hydrallazine and/or nitrates), digoxin, inotropes Selective beta blockers (bisoprolol), carvedilol (vasodilator) ACE inhibitors (after delivery) Inotropes Intraaortic balloon pump Left ventricular assist device Cardiac transplantation.

17 Mortality Recent series from South Africa, US quote mortality rates of 11-13% US data 0-19% Predictors of death / poor outcome Increased age, African, multiparous Reduced LVEF at presentation (<30%) increased LV size NYHA class Postpartum presentation Blauwet L & Sliwa K. Obstetric Medicine 2011.

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19 Predictors of cardiac events in pregnancy: Toronto study Cardiac Events predicted by: Prior cardiac event or arrhythmia NYHA classification > II or cyanosis LV Ejection fraction < 40% Left heart obstruction Mitral valve area < 2 cm 2 Aortic valve area < 1.5 cm 2 Aortic valve gradient > 30mmHg Siu et al Circulation 2001;104:515

20 Predictors of cardiac events in pregnancy: Toronto study Score 1 for each risk factor Score 0: Event risk 5% Score 1: Event risk 27% Score>1: Event risk 75% Drug treatment and method of delivery were not independent risk factors Siu et al Circulation 2001;104:515

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22 Congenital Heart Disease Modified WHO classification gives best risk estimation model for cardiac risk in pregnancy Balci A, Sollie-Szarynska KM, van der Bijl AGL, et al. Heart 2014;100: Page 22

23 Advise against pregnancy Pulmonary arterial hypertension Systemic ventricular dysfunction LVEF < 30%, NYHA III/IV Previous PPCM with any residual LV impairment Severe mitral stenosis Severe symptomatic aortic stenosis Aorta > 45mm Marfan Aorta > 50 mm bicuspid Severe coarctation

24 Pulmonary hypertension Non-pregnant mean PAP > 25 mmhg rest, > 30 on exercise or PVR > 200dy/sec/cm or >2.5 Woods Units (nb. catheter not echo) Danger relates to fixed increased pulmonary vascular resistance Inability to increase pulmonary blood flow with refractory hypoxaemia Most deaths can be attributed to thromboembolism hypovolaemia pre-eclampsia.

25 Pulmonary Hypertension Bedard, Dimopoulus, Gatzoulis Eur HJ 2009; 30:256 Systematic review pregnancies Idiopathic PAH (72% on advanced therapies) Congenital heart disease associated PAH (52%) Other PAH (47%) Overall mortality reduced = 38% (Yentis et al. BJOG 1998; 105: ) = 25% Idiopathic PAH 17% CHD PAH 28% Other PAH 33%

26 PAH targeted therapies Phosphodiesterase inhibitors (sildenafil) Endothelin-receptor antagonists (bosentan) Inhaled nitric oxide Prostacyclin analogues Page 26

27 Is Pulmonary Hypertension still a contraindication to pregnancy? Current Literature (limited to case series) Reported mortalities 7-17% Risk probably does relate to degree and vasoresponsiveness Individualized pre pregnancy counselling is essential Thorough assessment in PH centre Yes in most cases

28 CONTRACEPTION

29 Aortic Dissection More common in pregnancy 7-9 deaths every 3 yrs Risk factors Marfan s / Ehlers Danlos syndrome (type IV) / Turner s / bicuspid AoV / Coarctation Most are type A (ascending aorta) Most present late pregnancy/within a week post partum Chest pain often attributed to pulmonary embolism Severe and interscapular Associated hypertension Systolic hypertension ignored

30 Mitral stenosis Asymptomatic Sinus Rhythm No therapy MVA = 0.9cm 2

31 Learning points mitral stenosis 1. Severe mitral stenosis that is asymptomatic prior to and in early pregnancy may decompensate later in pregnancy and is potentially fatal 2. The fact that mitral stenosis is asymptomatic does not mean that it is mild and that pregnancy will be tolerated 3. Pulmonary oedema may present with wheezing 4. Rheumatic valve disease should always be considered in pregnant women from developing countries 5. Patients with mitral valve disease should be evaluated prepregnancy when possible

32 Which Anticoagulant Regimes for Mechanical Valves? Warfarin throughout Small mitral Bjork Shiley <5mg warfarin Heparin until 12/40, Warfarin until 36/40 Heparin Heparin + aspirin throughout Large aortic Bileaflet

33 LMWH vs Warfarin Aortic valve Newer valve Carbomedics Sinus rhythm Warfarin dose > 5mg Likely compliance with 2 injections / day Give adjunctive aspirin Mitral valve Older (smaller) valve Bjork shiley AF/ large LA Warfarin dose < 5mg > 1 mechanical valve Previous CVA / embolus

34 So what are the anticoagulation options in pregnant women with mechanical valves? Any strategy carries risks Women should participate in the choice of anticoagulation Women should be fully informed of risks and benefits of all options Decision should be individualized and ideally made pre pregnancy Care should be multidisciplinary

35 Cyanotic congenital heart disease Main risks = fetal < 20% chance of live birth if oxygen saturation < 80-85% Increased risk of Miscarriage FGR Maternal thromboembolism

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