Team-Based Care of Women With Cardiovascular Disease From Pre-Conception Through Pregnancy and Postpartum: JACC Focus Seminar 1/5

The specialty of cardio-obstetrics has emerged in response to the rising rates of maternal morbidity and mortality related to cardiovascular disease (CVD) during pregnancy. Women of childbearing age with or at risk for CVD should receive appropriate counseling regarding maternal and fetal risks of pregnancy, medical optimization, and contraception advice. A multidisciplinary cardio-obstetrics team should ensure appropriate monitoring during pregnancy, plan for labor and delivery, and ensure close follow-up during the postpartum period when CVD complications remain common. The hemodynamic changes throughout pregnancy and during labor and delivery should be considered with respect to the individual cardiac disease of the patient. The fourth trimester refers to the 12 weeks after delivery and is a key time to address contraception, mental health, cardiovascular risk factors, and identify any potential postpartum complications. Women with adverse pregnancy outcomes are at increased risk of long-term CVD and should receive appropriate education and longitudinal follow-up.     

Cardiovascular Imaging and Pregnancy

Cardiovascular disease (CVD) has become increasingly prevalent in women of childbearing age in the western world. This has led to CVD now being the leading cause of maternal morbidity and mortality. In the modern era optimal cardiology care is dependent on cardiovascular imaging and this is especially so in the appropriate management of the pregnant woman with CVD. CVD imaging allows for accurate risk assessment before pregnancy and guides appropriate management during pregnancy. In this article we outline the hemodynamic and structural changes that occur in the cardiovascular system in pregnancy. We examine the role of echocardiography, cardiac magnetic resonance imaging, computed tomography, and coronary angiography within the care of the pregnant patient and highlight the strengths and weaknesses of each.     

High Risk, High Stakes: Optimizing Cardiovascular Risk Assessment in Women

Women worldwide are at risk for cardiovascular disease (CVD), with CVD mortality accounting for > 50% of deaths in women in the United States. CVD risk stratification in women was traditionally similar to that in men, leading to under-detection of disease in women. Recently women-specific guidelines have raised awareness of female-specific risk factors. Pre-eclampsia has a striking correlation with increased CVD events in women decades after pregnancy. New serum markers of CVD such as C-reactive protein show promise of early detection but have uncertain clinical value since they may not help re-stratify women at intermediate risk. Imaging tests such as coronary artery calcium scoring and carotid intimal medial thickness have been investigated in women. They too may fail to recognize women at long-term increased risk and how to apply these tests clinically is uncertain. This article critically reviews new developments in risk stratification of CVD in women.     

Echocardiography in Pregnancy: Part 1

Cardiovascular disease (CVD) remains the leading cause of maternal mortality, and clinical diagnosis of CVD in women during pregnancy is challenging. Pregnant women with known heart disease require careful multidisciplinary management by obstetric and medical teams to assess for maternal and fetal risk. Echocardiography is a safe and effective diagnostic tool indicated in pregnant women with cardiac symptoms or women with known cardiac disease for appropriate selection of women who require close monitoring of cardiac condition and valvular function. Echocardiography is the single most important clinical tool to diagnose and manage heart disease during pregnancy. Echocardiography is able to characterize cardiac structural abnormalities and corresponding hemodynamic changes, identifies heart diseases that are poorly tolerated in pregnancy, and helps select patients who may require a cesarean delivery because of hemodynamic instability. An understanding of the physiologic alterations including increased heart rate, blood volume, and cardiac output as well as the decreased vascular resistance is important for early recognition and monitoring of the consequences of cardiac disease in pregnancy. This review will focus on common acquired cardiac lesions encountered during pregnancy and the role of echocardiography in the diagnosis and management of these diseases.     

Pregnancy in women with congenital heart disease

Congenital heart disease is the most common form of structural heart disease affecting women of childbearing age in developed countries. Pregnancy in these patients is associated with an increased risk to both mother and fetus. Appropriate prepregnancy evaluation and counseling is recommended to assess the pregnancy-related maternal and fetal risk and to identify patients who should avoid pregnancy. Once pregnancy occurs, cardiovascular reevaluation is generally recommended; the frequency is individualized. Monitoring during delivery may be necessary and the post-partum period is a concern in select individuals. Data regarding the outcome of pregnancy in patients with operated congenital cardiac defects are available. Individualized care is mandatory.     

Practice Guidelines of the Spanish Society of Cardiology for the management of cardiac disease in pregnancy

Maternal adaptation to pregnancy includes reproductive hormone interaction plasma, volume changes with an increase in total body water, vascular alterations with a decrease in systemic resistance and modifications associated with hypercoagulability. These explain, in part, the appearance of signs and symptoms, even in a normal pregnant woman, that are difficult to distinguish from those occurring in heart disease and why some cardiac abnormalities are not well tolerated during pregnancy. Cardiovascular abnormalities are considered the first non-obstetric cause of morbidity and mortality during pregnancy. Rheumatic and congenital heart diseases are currently the most frequent cardiopathy found in women of childbearing age, followed by hypertension, coronary artery disease and arrhythmia. Although pregnancy is well tolerated by most women with heart disease, there are some cardiovascular abnormalities which place the mother and the infant at extremely high risk: patients with congestive heart failure and severe cardiac dysfunction, pulmonary hypertension, cyanotic congenital heart disease, Marfan's syndrome, severe obstructive lesions of the left side of the heart, patients with prosthetic cardiac valves and antecedents of peripartum cardiomyopathy should be encouraged to avoid pregnancy and the interruption of pregnancy may be advisable in cases with great risk of disability or death. The most severe cardiopathies significantly increase the risk of fetal loss and the presence of a congenital cardiac abnormality in either parent increases the risk of congenital cardiac disease in the fetus. Medical care must be initiated early, prior to conception and women with cardiopathy should be informed of the possible risks of pregnancy to both the mother and fetus.     

Management of Women With Acquired Cardiovascular Disease From Pre-Conception Through Pregnancy and Postpartum: JACC Focus Seminar 3/5

Acquired cardiovascular conditions are a leading cause of maternal morbidity and mortality. A growing number of pregnant women have acquired and heritable cardiovascular conditions and cardiovascular risk factors. As the average age of childbearing women increases, the prevalence of acute coronary syndromes, cardiomyopathy, and other cardiovascular complications in pregnancy are also expected to increase. This document, the third of a 5-part series, aims to provide practical guidance on the management of such conditions encompassing pre-conception through acute management and considerations for delivery.     

Coronary Events in the Pregnant Patient: Who Is at Risk and How Best to Manage?

Coronary events in pregnancy are a rare but growing cause of maternal morbidity and mortality. Pregnancy presents unique challenges across a broad spectrum of disciplines and requires a multidisciplinary approach to optimise maternal and fetal outcomes. The early involvement of the “cardio-obstetrics” team in prepregnancy counselling, the antenatal period, delivery, and postpartum is vital to ensuring better outcomes for patients at high risk of coronary pathology. The overall risk for coronary events complicating pregnancy is increasing owing to a number of factors, including advancing maternal age and increases in traditional cardiac risk factors contributing to higher rates of maternal morbidity and mortality. The majority of pregnant women experiencing a coronary event do not have previous coronary disease, and the pathologic mechanisms involved are predominantly nonatherosclerotic. Diagnosis and management should follow standard guideline-based practices for acute coronary syndrome (ACS), including the use of diagnostic coronary angiography to guide percutaneous intervention when needed. Management of ACS should not be delayed to facilitate delivery, which can proceed following stent implantation and dual antiplatelet therapy. The timing and mode of delivery should be based on assessment of maternal and fetal status, but vaginal delivery is preferred when possible. This review aims to provide an overview of the major etiologies, risk factors, diagnoses, and management strategies for patients at risk of or presenting with coronary events in pregnancy.     

Integrating Biomarkers and Imaging for Cardiovascular Disease Risk Assessment in Diabetes

Cardiovascular disease (CVD) risk assessment has changed substantially in recent years. While older guidelines considered diabetes a coronary disease risk equivalent, more recent guidelines recommend risk stratification on the basis of global risk scoring to target intensity of therapy. While patients with diabetes as a whole are at greater risk for CVD events, these patients may also benefit from risk stratification based on circulating biomarkers like high-sensitivity C-reactive protein, high-sensitivity cardiac troponin T, and N-terminal pro-B-type natriuretic peptide, as well as newer imaging modalities (coronary artery calcium, carotid intima-media thickness, and myocardial perfusion imaging). The addition of these CVD risk assessment modalities could play an important role for deciding how aggressive a physician should be with pharmacological therapy. Here, we discuss many of the current recommendations of CVD risk assessment in patients with diabetes including newer modalities for CVD risk assessment.     

Cardiovascular diseases in women: a statement from the policy conference of the European Society of Cardiology.

Cardiovascular diseases (CVD) are the leading cause of mortality both in men and women. In Europe, about 55% of all females' deaths are caused by CVD, especially coronary heart disease and stroke. Unfortunately, however, the risk of heart disease in women is underestimated because of the perception that women are 'protected' against ischaemic heart disease. What is not fully understood is that women during the fertile age have a lower risk of cardiac events, but this protection fades after menopause thus leaving women with untreated risk factors vulnerable to develop myocardial infarction, heart failure, and sudden cardiac death. Furthermore, clinical manifestations of ischaemic heart disease in women may be different from those commonly observed in males and this factor may account for under-recognition of the disease. The European Society of Cardiology has recently initiated an extensive 'Women at heart' program to coordinate research and educational initiatives on CVD in women. A Policy Conference on CVD in Women was one of the first steps in the development of this program. The objective of the conference was to collect the opinion of experts in the field coming from the European Society of Cardiology member countries to: (1) summarize the state-of-the-art from an European perspective; (2) to identify the scientific gaps on CVD in women; and (3) to delineate the strategies for changing the misperception of CVD in women, improving risk stratification, diagnosis, and therapy from a gender perspective and increasing women representation in clinical trials. The Policy Conference has provided the opportunity to review and comment on the current status of knowledge on CVD in women and to prioritize the actions needed to advance this area of knowledge in cardiology. In the preparation of this document we intend to provide the medical community and the stakeholders of this field with an overview of the more critical aspects that have emerged during the discussion. We also propose some immediate actions that should be undertaken with the hope that synergic activities will be implemented at European level with the support of national health care authorities.     

Referral to Cardiology Following Postpartum Cardiovascular Risk Screening at the Maternal Health Clinic in Kingston,Ontario

BackgroundCardiovascular disease (CVD) is the leading cause of death globally among women, and certain pregnancy complications can be the earliest indicators of increased CVD risk. Nonetheless, there is no recommendation for follow-up of cardiovascular risk factors identified through postpartum screening programs. This study describes current referral practices and clinical course from the Maternal Health Clinic in Kingston, Ontario, for women deemed at high cardiovascular risk postpartum.MethodsWe investigated the cohort of women referred from the postpartum Maternal Health Clinic to cardiology for further assessment and management, specifically examining timing and recommended interventions to reduce CVD risk.ResultsWomen referred to cardiology differed significantly from those not referred in history of hypertensive disorders of pregnancy (P < 0.05) and demonstrated a significantly worse CVD risk profile at 6 months postpartum (P < 0.0001). Life expectancy by the cardiometabolic model for women referred was 5 years shorter (P < 0.0001). Only half of the women referred to cardiology scheduled a visit; the median time to the scheduled appointment was 12 months. Of women seen by cardiology, 60% were deemed eligible for cardiac rehabilitation.ConclusionsAlthough women at highest risk for CVD are being identified and referred to cardiology, the existing system is not designed for this demographic. Too many women are missing their appointments or being seen beyond 1 year postpartum. To initiate lifestyle changes and/or therapeutic interventions, we suggest that CVD prevention programming begins within 1 year of delivery. Future studies should investigate the viability of traditional cardiac rehabilitation programs among this unique population.     

Cardiac arrhythmias in pregnancy: clinical and therapeutic considerations

Pregnancy can precipitate cardiac arrhythmias not previously present in seemingly well individuals. Risk of arrhythmias is relatively higher during labor and delivery. Potential factors that can promote arrhythmias in pregnancy and during labor and delivery include the direct cardiac electrophysiological effects of hormones, changes in autonomic tone, hemodynamic perturbations, hypokalemia of pregnancy, and underlying heart disease. Paroxysmal supraventricular and ventricular tachycardia may cause hemodynamic compromise with consequences to the fetus. Management of arrhythmias in pregnant women is similar to that in non-pregnant but a special consideration must be given to avoid adverse fetal effects. No drug therapy is usually needed for the management of supraventricular or ventricular premature beats, but potential stimulants, such as smoking, caffeine, and alcohol should be eliminated. In paroxysmal supraventricular tachycardia, vagal stimulation maneuvers should be tried first. Adenosine or a cardioselective beta-blocker could be used if vagal maneuvers are ineffective. Alternatively, verapamil or diltiazem may be given. In pregnant women with atrial fibrillation, the goal of treatment is conversion to sinus rhythm or to control ventricular rate by a cardioselective beta-adrenergic blocker drug or digoxin. Ventricular arrhythmias may occur in the pregnant women with cardiomyopathy, congenital heart disease, valvular heart disease, or mitral valve prolapse. Termination of ventricular arrhythmias can usually be achieved by intravenous lidocaine or procainamide or by electrical cardioversion. Amiodarone is not safe for the fetus. Beta-blocker therapy must be continued during pregnancy and postpartum period in women with long QT syndrome and torsade de pointes.     

Pregnancy and delivery in cardiac disease

Although its prevalence is relatively low in pregnant women, heart disease is the most important cause of maternal mortality. Problems may arise due to hemodynamic burden and the hypercoagulable state of pregnancy. Heart disease may be congenital or acquired. In developed countries, the former composes the biggest part of women with heart disease. Patients with unrepaired lesions, cyanotic lesions, diminished systemic ventricular function, complex congenital heart disease, left ventricular outflow tract obstruction, pulmonary hypertension, or mechanical valves are at highest risk of developing complications during pregnancy.All patients with known cardiac disease should preferably be counseled before conception. Pre-pregnancy evaluation should include risk assessment for the mother and fetus, including medication use and information on heredity of the cardiac lesion. Management of pregnancy and delivery should be planned accordingly on individual bases. The types of complications are related to the cardiac diagnosis, with arrhythmias and heart failure being most common. Treatment options should be discussed with the future parents, as they may affect both mother and child. In general, the preferred route of delivery is vaginal. The optimal care for pregnant women with heart disease requires multidisciplinary involvement and is best concentrated in tertiary centers.     

Use of Medication for Cardiovascular Disease During Pregnancy: JACC State-of-the-Art Review

Cardiovascular disease complicating pregnancy is rising in prevalence secondary to advanced maternal age, cardiovascular risk factors, and the successful management of congenital heart disease conditions. The physiological changes of pregnancy may alter drug properties affecting both mother and fetus. Familiarity with both physiological and pharmacological attributes is key for the successful management of pregnant women with cardiac disease. This review summarizes the published data, available guidelines, and recommendations for use of cardiovascular medications during pregnancy. Care of the pregnant woman with cardiovascular disease requires a multidisciplinary team approach with members from cardiology, maternal fetal medicine, anesthesia, and nursing.     

Gestational Diabetes: Implications for Cardiovascular Health

Gestational diabetes mellitus (GDM) is a pregnancy complication that is becoming more prevalent with recent population trends in obesity and advancing maternal age. A diagnosis of GDM not only increases risk for maternal and fetal complications during pregnancy, but also significantly increases a woman’s risk of both type 2 diabetes mellitus (T2DM) and cardiovascular disease (CVD) in the postpartum. Even women with milder forms of abnormal glucose homeostasis during pregnancy, specifically gestational impaired glucose tolerance, are at increased risk, justifying the recent recommendation to tighten the diagnostic criteria for GDM, thus implicating many more women. Risk factors that increase risk for future CVD among women with a history of GDM include postpartum progression to T2DM; metabolic syndrome; obesity; hypertension; and altered levels of circulating inflammatory markers, specifically, adiponectin, C-reactive protein, and tumor necrosis factor-α. Medical therapies such as metformin that prevent progression to T2DM may prove to be our primary defense against earlier CVD among women with GDM.     

Links Between Maternal Cardiovascular Disease and the Health of Offspring

Maternal cardiovascular disease (CVD) during pregnancy is on the rise worldwide, as both more women with congenital heart disease are reaching childbearing age, and conditions such as diabetes, hypertension, and obesity are becoming more prevalent. However, the extent to which maternal CVD influences offspring health, as a neonate and later in childhood and adolescence, remains to be fully understood. The thrifty phenotype hypothesis, by which a fetus adapts to maternal and placental changes to survive a nutrient-starved environment, may provide an answer to the mechanism of maternal CVD and its impact on the offspring. In this narrative review, we aim to provide a review of the literature pertaining to the impact of maternal cardiovascular and hypertensive disease on the health of neonates, children, and adolescents. This review demonstrates that maternal CVD leads to higher rates of complications among neonates. Ultimately, our review supports the hypothesis that maternal CVD leads to intrauterine growth restriction (IUGR), which, through the thrifty phenotype hypothesis and vascular remodelling, can have health repercussions, including an impact on CVD risk, both in the immediate newborn period as well as later throughout the life of the offspring. Further research remains crucial in elucidating the mechanism of maternal CVD long-term effects on offspring, as further understanding could lead to preventive measures to optimise offspring health, including modifiable lifestyle changes. Potential treatments for this at-risk offspring group could mitigate risk, but further studies to provide evidence are needed.     

Diagnostic Cardiovascular Imaging and Therapeutic Strategies in Pregnancy: JACC Focus Seminar 4/5

The prevalence of cardiovascular disease (CVD) in pregnancy, both diagnosed and previously unknown, is rising, and CVD is a leading cause of maternal morbidity and mortality. Historically, women of child-bearing potential have been underrepresented in research, leading to lasting knowledge gaps in the cardiovascular care of pregnant and lactating women. Despite these limitations, clinicians should be familiar with the safety of frequently used diagnostic and therapeutic interventions to adequately care for this at-risk population. This review, the fourth of a 5-part series, provides evidence-based recommendations regarding the use of common cardiovascular diagnostic tests and medications in pregnant and lactating women.     

Pregnancy in women with heart defects: outlook on the problem

Modern approach to management of pregnancy and delivery in women with heart defects is presented in this paper. The 3-level system of observation of this contingent of patients is based on stratification of risk of development of cardiological complications which allows to form an algorithm of physicians actions, and to optimize tactics of ambulatory and hospital stages of treatment. Stratification of risk is supplemented with quantitative echocardiographic parameters which reflect hemodynamic overload of the myocardium and facilitate work of a practical physician. Special consideration is given to pregnant women subjected to palliative cardiac surgery. If contractile function is preserved these women have good prognosis relative to prolongation of pregnancy and unassisted delivery.     

Pregnancy in women with type 2 diabetes: an uncertain prognosis

The increasing prevalence of type 2 diabetes in women of childbearing age leads to an increasing number of pregnant women with type 2 diabetes. Pregnancy complicated by type 2 diabetes is a high-risk pregnancy, associated with birth defects and high perinatal mortality to the same extent as in type 1 diabetes. Until now, most attention was directed toward women with type 1 diabetes. Recent data stresses the urgent need to develop better screening and efficient care strategies in women with type 2 diabetes, who also display many risk factors for adverse fetal outcome. Family physicians, diabetologists and gynaecologists must be aware of this growing concern. Improvement of pregnancy planning, adequate metabolic control from conception to delivery and a multi-disciplinary team approach to care should improve fetal and maternal outcomes. Furthermore, diabetes screening in high-risk women prior to pregnancy is warranted.     

Pregnancy following liver transplantation: Review of outcomes and recommendations for management

Liver transplantation is considered to be the treatment of choice for end-stage liver disease and its success has led to an increase in the number of female liver transplant recipients who are of childbearing age. Several key issues that are noted when counselling patients who are considering pregnancy following liver transplantation include the optimal timing of pregnancy, optimal contraception methods and the management of immunosuppression during pregnancy. The present review summarizes the most recent literature so that the clinician may address these issues with their patient and enable them to make informed decisions about pregnancy planning. The authors review recent studies examining maternal and fetal outcomes, and the rates of complications including risk of graft rejection. Subsequently, the authors provide recommendations for counselling prospective mothers and the management of the pregnant liver transplant recipient.