P redictors of Cardiac D isease in Pregnancy

PREDICTORS OF CARDIAC DISEASE IN PREGNANCY

Golnaz Houshmand.MD Cardiologist

Why we concern !

Approximately 2% of pregnancies involve maternal cardiovascular disease, associated with increased risk to both mother and fetus.

Heart disease is the third most common cause of maternal death and the leading non-obstetric cause.

In 2011, guidelines on the prevention of cardiovascular disease in women identified pregnancy complications as risk factors for cardiovascular disease.

Pulmonary embolism, arrhythmias, pre-eclampsia and peripartum cardiomyopathy, develop as a complication of pregnancy in previously healthy women.

women with pre-existing heart disease may be predisposed to some of these complications and less able to cope with them

Advances in the practice of cardiology , The increasing success of neonatal surgery allows more infants with complex anomalies to reach adulthood, wanting normal lives with jobs and families.

Career women postponing pregnancy account for larger numbers of older patients with hypertension and coronary disease

hemodynamic

during the first trimester steep increase in plasma volume, which causes dilution and anemia.

The stroke volume and, to a lesser extent, the heart rate increase and the cardiac output increases progressively. (around 40–50% above the pre-pregnancy.)

Accompanying decrease in vascular resistance, and diastolic and mean blood pressure.

In cyanotic or potentially cyanotic congenital heart disease, The drop in peripheral vascular

resistance encourages right-to-left shunting, leading to increasing cyanosis

Rise in hematocrit with increased risk of thrombosis and paradoxical embolism.

When trouble occurs it usually begins early, often by the end of the first trimester.

These considerations are of pivotal importance if the physician is to advise the woman correctly and not simply retreat with the easy option of advising against pregnancy or encouraging early termination

Significant heart conditions are usually known about before pregnancy but important exceptions are: Pulmonary hypertension, Mitral stenosis, Cardiomyopathies Fragile Aorta ASD Coronary Artery Disease

PMH &Examination

Many disorders are apparent from the personal and family history, particularly cardiomyopathies, Marfan syndrome and congenital heart disease.

Ask specifically for possible sudden deaths in the family

There may be previous knowledge of a cardiac murmur, which may or may not be linked to a specific valve disease.

The outcome of any previous pregnancies (hypertension, pre-eclampsia, pulmonary emboli or peripartum cardiomyopathy)

An understanding of the normal findings on cardiac examination in a pregnant patient is important

Normal clinical findings that can mimic heart disease in pregnancy

Raised jugular venous pressure (prominent ‘a’ and ‘v’ waves, brisk ‘x’ and ‘y’ descents)

Volume-loaded left ventricle; full, sharp and collapsing pulse Warm extremities Peripheral edema Palpitations Tachycardia Premature atrial/ventricular beats Increased intensity of mitral closure sound Third heart sound (rapid ventricular filling and is found in up to

90%) Systolic murmur (90%) Continuous murmur from venous hum, mammary soufflé

A cervical venous hum, best heard over the supraclavicular fossa, is common in children, and is also found in pregnancy.

The mammary murmur, either systolic or continuous, is heard maximally at the second left or right intercostal space during late pregnancy in some women.

differentiated from a persistent arterial duct by applying gentle pressure, makes the mammary murmur disappear.

An ejection systolic murmur never more than grade 3/6 in intensity

There should be no diastolic murmur.

Electrocardiography

The heart rate may be increased by 10–15%. Re-entrant supraventricular tachycardia is a

relatively common benign arrhythmia. persistent sinus tachycardia, atrial

flutter, atrial fibrillation or ventricular tachycardia suggests underlying heart disease and should prompt further investigation.

The appearance of ventricular tachycardia in late pregnancy or in the puerperium should arouse suspicion of peripartum cardiomyopathy.

ECHOCARDIOGRAPHY

Referral is often triggered by the detection of a systolic murmur by the obstetrician

Occasionally, the distinction between normality and abnormality may be subtle and an expert interpretation should be sought before the final report.

In most pregnancies echocardiography will reassure the mother-to-be who can then continue to enjoy her pregnancy.

A progressively increasing awareness in pregnant women during the third trimester is the presence of breathlessness.

A common symptom during pregnancy, this may be difficult to distinguish from breathlessness related to the onset of peripartum cardiomyopathy.

New onset of intraventricular conduction delay or left bundle-branch block on the ECG, together

with an ‘unusual’ breathlessness, should constitute an absolute indication for an early echocardiographic examination to assess left ventricular function.

RISK ASSESSMENT

Worrisome predictors of maternal cardiac events include(from the CARPREG study) (1) prior cardiac event (e.g., heart failure, transient

ischemic attack, or stroke before pregnancy) or arrhythmia;

(2) baseline New York Heart Association (NYHA) class higher than class II or cyanosis;

(3) left-sided heart obstruction (mitral valve area smaller than 2 cm2, aortic valve area less than 1.5 cm2, or peak left ventricular outflow tract gradient greater than 30 mm Hg as assessed by echocardiography);

(4)ejection fraction less than 40%

When none of the risk factors was present, the risk of a cardiovascular complication during pregnancy was less than 5%

The presence of one of the above risk factor, a risk of a cardiovascular complication during pregnancy of over 20%

more than one risk factor, the risk of a cardiovascular comaplication during pregnancy was over 70%.

WHO CLASSIFICATION

WHO I

• Uncomplicated, small or mild - PS - PDA - MVP• Successfully repaired simple lesions (ASD or VSD, PDA, PAPVC).• Atrial or ventricular ectopic beats, isolated

WHO II or III

WHO II (if otherwise well and uncomplicated)

• Unoperated ASD ,VSD• Repaired tetralogy of Fallot• Most arrhythmias

WHO II–III (depending on individual)• Mild left ventricular impairment• HCM• Native or tissue valvular heart disease not considered WHO I or IV• Marfan syndrome without aortic dilatation• Aorta <45 mm in aortic disease associated with bicuspid aortic valve• Repaired coarctation

WHO III

• Mechanical valve• Systemic right ventricle • Fontan circulation• Cyanotic heart disease (unrepaired)• Other complex congenital heart disease • Aortic dilatation 40–45 mm in Marfan syndrome• Aortic dilatation 45–50 mm in aortic disease associated with bicuspid aortic valve

WHO IV(pregnancy contraindicated)

• Severe PAH of any cause• Severe systemic ventricular dysfunction (LVEF <30%, NYHA III–IV)• Previous peripartum cardiomyopathy with any residual impairment of left ventricular function• Severe MS, severe AS• Marfan syndrome with aorta dilated >45 mm• Aortic dilatation >50 mm in aortic disease associated with bicuspid aortic valve• Native severe coarctation

The highest maternal mortality from heart disease is in patients with pulmonary hypertension, whether idiopathic, or associated with other disease or with reversed central shunt in Eisenmenger syndrome. The maternal mortality rate may be as high as 50%

Most women with heart disease who are in New York Heart Association class I or II before pregnancy accomplish pregnancy safely.

Valve regurgitation is generally well tolerated during pregnancy, primarily because of the afterload reduction and increased heart rate.

Patients with simple congenital cardiac defects do well

Most patients with heart disease do well.

Congenital Heart Disease

The category of patients with congenital heart disease who have had previous surgery. If the operation were ‘corrective’, pregnancy

would usually proceed normally but would sometimes be complicated by arrhythmia, (usually benign), and endocarditis.

Patients who have undergone palliative surgery may be at risk of heart failure or thromboembolism as well as infection and arrhythmia.

Echocardiography and transesophageal imaging helps both in initial assessment of risk and in serial documentation of progress.

Cardiac magnetic resonance imaging (MRI) may be complementary

A comprehensive pre-pregnancy assessment is recommended for all patients with a history of operated or unoperated congenital heart disease

Optimal management of the pregnant patient with congenital heart disease includes accurate diagnosis, and the correct prediction of the hemodynamic consequences of both the pregnancy on the cardiac disorder and the cardiac disorder on the baby’s development.

FETAL ECHO

the woman with congenital heart disease, a fetal cardiac echocardiogram can start at week 14 and is offered at approximately 18 to 22 weeks of pregnancy to determine whether a congenital cardiac anomaly is present.

Cardiomyopathies

HCM

Parents should be informed about the autosomal dominant inheritance pattern, which has variable penetrance. genetic counseling and family screening are appropriate before pregnancy

The left ventricle seems to fill better during pregnancy and without undue rise in filling pressure in most cases.

Pressure gradients may be high but usually do not affect outcome

Generally, hypertrophic cardiomyopathy is well tolerated during pregnancy.

Patients with significant symptoms before pregnancy may not do well and become hemodynamically unstable.

Common symptoms include palpitation, angina, and breathlessness. In a study of 127 women with 271 pregnancies, 36 women (28.3%) reported cardiac symptoms but 90% were symptomatic before pregnancy

DCM

When discovered late in pregnancy, dilated cardiomyopathy may be regarded as peripartum because of its temporal relationship with pregnancy

when detected earlier in pregnancy the condition is likely to have been pre-existing.

Echocardiography shows a hypokinetic left ventricle that may or may not be dilated.

Patients with idiopathic dilated cardiomyopathy usually are counseled not to have a pregnancy if the ejection fraction is lower than 40%.

Exercise testing also may be helpful, because women with ejection fractions of 40% to 50% may not tolerate pregnancy well if they have a poor functional aerobic capacity

PPCM

Occurring during the last months of pregnancy or within 5 months of delivery in previously healthy women.

Cardiac imaging (usually with echocardiography) is essential to establish the diagnosis.

The higher incidence in some countries suggests the influence of environmental risk factors or a common genetic mutation.

Known risk factors include multiparity, black race, older maternal age, and particularly preeclampsia

Normalization of ventricular function occurs in approximately 23% to 54% of patients with PPCM more likely if the ejection fraction is greater

than 30% at the time of diagnosis. Most physicians counsel against a second

pregnancy, even if the ventricular function does return to normal, PPCM will recur in approximately 30% of cases.

recurrence may result in significant clinical deterioration and even death.

Fragile Aorta

Women with Marfan syndrome are always a worry in pregnancy.

The family history is important and serial measurement of aortic root diameter are important. ( family history of aortic rupture or evidence of aortic root widening)

Dissection occurs most often in the last trimester of pregnancy (50%) or the early postpartum period (33%).

The diagnosis of aortic dissection should be considered in all patients with chest pain during pregnancy.

THANKS FOR YOUR ATTENTION