Meeting NewsPerspective

ESC guideline on CVD, pregnancy emphasizes monitoring, counseling

Jolien Roos-Hesselink 2018
Jolien W. Roos-Hesselink

MUNICH — Counseling, monitoring and management of women with CVD is critical during pregnancy, according to an updated guideline presented at the European Society of Cardiology Congress.

“Pregnancy is complicated by maternal disease in 1% to 4% of cases,” Vera Regitz-Zagrosek, director of the Institute of Gender in Medicine at Charité – Universitätsmedizin Berlin and chairperson of the writing committee, said in the presentation. “Cardiovascular diseases are still the most common causes of maternal death in Europe.”

Although MI and ACS are fairly uncommon in women during pregnancy, CAD is the cause for greater than 20% of all maternal cardiac deaths, according to the presentation. Most instances of CAD in pregnant women have non-atherosclerotic mechanisms such as angiographically normal coronary arteries, pregnancy-related spontaneous coronary artery dissection and coronary thrombosis. The preferred reperfusion strategy in pregnant women is primary PCI.

Some diseases such as those related to hypertrophy, peripartum cardiomyopathy, toxic, Takotsubo cardiomyopathy and storage diseases are rare, but have been shown to cause major complications during pregnancy and lead to maternal death, according to the authors.

Management goals for pregnant women are similar to those for acute HF outside of pregnancy, which include avoiding fetotoxic agents including ACE inhibitors, angiotensin receptor-neprilysin inhibitors, angiotensin II receptor antagonists and mineralocorticoid receptor antagonists.

In addition, bromocriptine is starting to emerge as a new concept for the management of acute HF, especially when added with anticoagulation, according to the presentation.

Before determining the best treatment option, initial evaluation of the patient should include an assessment of HF severity and a diagnosis confirmation. From there, treatment can be stratified by pregnancy stage and severity of the patient’s condition.

"What is very important is if you do see a woman with peripartum or dilated cardiomyopathy, she must be counseled there is a major risk for deterioration in a subsequent pregnancy if the ejection fraction does not normalize," Regitz-Zagrosek said.

Atrial fibrillation and paroxysmal supraventricular tachycardia are the most frequent arrhythmias in pregnant women, which are typically benign and can be treated effectively. Rare arrhythmias include ventricular tachycardia, ventricular fibrillation, bradyarrhythmia and conduction disturbances.

“Our guidelines provide for the first time a scheme where we clearly indicate the risk for arrhythmia and the risk that is put by a specific arrhythmia on a patient, we tell you which arrhythmias go into these classes associated with low risk, with medium risk and high risk,” Regitz-Zagrosek said. “This determines the surveillance level at delivery.”

Hypertension affects 5% to 10% of pregnancies, according to the presentation. One of the new recommendations from this guideline is that weight gain should be limited for pregnant women with obesity to less than 6.8 kg.

The guideline includes a table on drug and safety data which gives a classification based on safety and risks to mother and child. This also includes mention of the former FDA categories.

“This classification was stopped by the FDA and should no longer be the basis of our therapeutic decisions now,” Regitz-Zagrosek said. “Nevertheless, it is helpful and we are still providing it for the older drugs where this classification is available.”

Other information in this table include pre-clinical and clinical safety data.

“This was really an enormous work to put this together and I think now it’s the most reliable and the most comprehensive source on what is known of the potential of different drugs to generate harm to the mother or to the fetus,” Regitz-Zagrosek said.

Compared with women who are not pregnant, those who are do not have different indications for intervention such as those involving surgery or catheters, according to the presentation. Some exceptions are severe asymptomatic mitral stenosis and severe aortic dilation.

Women with suspected or known congenital or acquired CV and aortic disease are recommended to undergo pre-pregnancy risk assessment and counseling. Though this, the modified WHO classification of maternal risk should be used to assess women with cardiac disease of childbearing age and after conception.

The recommendations also suggest that a multidisciplinary pregnancy heart team should treat women at high risk.

“It doesn’t imply that in every hospital, you should have this pregnancy heart team, but you can also consult on the distance level,” Jolien W. Roos-Hesselink, MD, PhD, of the department of cardiology at Erasmus University Rotterdam in the Netherlands, said during the presentation. “Just contact such a center where you know that there is expertise in pregnancy and cardiac disease and try to discuss this patient timely, so you can prevent the complications to occur and to make a good pregnancy plan.”

A pregnancy heart team should also be consulted when deciding upon a valve prosthesis in women who are thinking about getting pregnant.

Pre-pregnancy counseling should include maternal risk for complications during pregnancy, possible irreversible effects, fetal risk, genetic aspects, medication use and long-term prognosis of the mother, according to the presentation.

The pregnancy heart team should at least have a cardiologist, an obstetrician/gynecologist and an anesthetist.

“They have to have experience in pregnancy and heart disease,” Roos-Hesselink said.

When necessary, other specialists should join the team, including a hematologist, a cardiothoracic surgeon and an internal medicine specialist.

According to the modified WHO 4, women who should be counselled against pregnancy include those with Fontan operation and additional comorbidities including arrhythmias, ventricular dysfunction or valve regurgitation. Other conditions include those such as pulmonary arterial hypertension, severe systemic ventricular dysfunction, severe re-coarctation, systemic right ventricle with moderate or severely decreased ventricular function, severe aortic dilatation or history of aortic dissection and severe mitral stenosis even when asymptomatic.

During pregnancy, women with congenital or other genetic heart disease should undergo a fetal echocardiogram between 19 weeks and 22 weeks of pregnancy. Between 20 weeks and 30 weeks, a delivery plan should be made which focuses on induction, labor management, delivery and postpartum surveillance. If anticoagulation is necessary for a pregnant woman, low molecular weight heparin should only be used if the woman undergoes weekly monitoring of anti-Xa levels.

A new recommendation in this guideline is that pregnant women with cardiac disease should have induced labor at 40 weeks of gestation.

“This will have a clinical impact, but we think that there are no advantages for the mother and no disadvantages for the baby,” Roos-Hesselink said.

Vaginal delivery is preferred for most patients, but caesarean section may be indicated for those with aggressive aortic pathology, pre-term labor in patients on oral anticoagulants, acute intractable HF and severe forms of pulmonary hypertension. In addition, endocarditis prophylaxis is not recommended for women. Postpartum monitoring is also critical, according to the presentation.

“The period after delivery is an important period often neglected a little bit,” Roos-Hesselink said. “Many complications occur in the first 3 to 5 days after delivery.”– by Darlene Dobkowski

References:

Regitz-Zagrosek V, et al. ESC Clinical Practice Guidelines. Presented at: European Society of Cardiology Congress; Aug. 25-29, 2018; Munich.

Regitz-Zagrosek V, et al. Eur Heart J. 2018;doi:10.1093/eurheartj/ehy340.

Disclosures : Regitz-Zagrosek reports she has financial relationships with Berlin Chemie AG, Cognomed, Novartis, Pfizer, Saarländischer Hausärzteverband, Verband deutscher Unternehmerinnen, Vinzenz von Paul Kliniken gGmbH and Zahnmedizinisches Fortbildungszentrum. Roos-Hesselink reports no relevant financial disclosures. Please see the guideline for all other authors’ relevant financial disclosures.

Jolien Roos-Hesselink 2018
Jolien W. Roos-Hesselink

MUNICH — Counseling, monitoring and management of women with CVD is critical during pregnancy, according to an updated guideline presented at the European Society of Cardiology Congress.

“Pregnancy is complicated by maternal disease in 1% to 4% of cases,” Vera Regitz-Zagrosek, director of the Institute of Gender in Medicine at Charité – Universitätsmedizin Berlin and chairperson of the writing committee, said in the presentation. “Cardiovascular diseases are still the most common causes of maternal death in Europe.”

Although MI and ACS are fairly uncommon in women during pregnancy, CAD is the cause for greater than 20% of all maternal cardiac deaths, according to the presentation. Most instances of CAD in pregnant women have non-atherosclerotic mechanisms such as angiographically normal coronary arteries, pregnancy-related spontaneous coronary artery dissection and coronary thrombosis. The preferred reperfusion strategy in pregnant women is primary PCI.

Some diseases such as those related to hypertrophy, peripartum cardiomyopathy, toxic, Takotsubo cardiomyopathy and storage diseases are rare, but have been shown to cause major complications during pregnancy and lead to maternal death, according to the authors.

Management goals for pregnant women are similar to those for acute HF outside of pregnancy, which include avoiding fetotoxic agents including ACE inhibitors, angiotensin receptor-neprilysin inhibitors, angiotensin II receptor antagonists and mineralocorticoid receptor antagonists.

In addition, bromocriptine is starting to emerge as a new concept for the management of acute HF, especially when added with anticoagulation, according to the presentation.

Before determining the best treatment option, initial evaluation of the patient should include an assessment of HF severity and a diagnosis confirmation. From there, treatment can be stratified by pregnancy stage and severity of the patient’s condition.

"What is very important is if you do see a woman with peripartum or dilated cardiomyopathy, she must be counseled there is a major risk for deterioration in a subsequent pregnancy if the ejection fraction does not normalize," Regitz-Zagrosek said.

Atrial fibrillation and paroxysmal supraventricular tachycardia are the most frequent arrhythmias in pregnant women, which are typically benign and can be treated effectively. Rare arrhythmias include ventricular tachycardia, ventricular fibrillation, bradyarrhythmia and conduction disturbances.

“Our guidelines provide for the first time a scheme where we clearly indicate the risk for arrhythmia and the risk that is put by a specific arrhythmia on a patient, we tell you which arrhythmias go into these classes associated with low risk, with medium risk and high risk,” Regitz-Zagrosek said. “This determines the surveillance level at delivery.”

Hypertension affects 5% to 10% of pregnancies, according to the presentation. One of the new recommendations from this guideline is that weight gain should be limited for pregnant women with obesity to less than 6.8 kg.

The guideline includes a table on drug and safety data which gives a classification based on safety and risks to mother and child. This also includes mention of the former FDA categories.

“This classification was stopped by the FDA and should no longer be the basis of our therapeutic decisions now,” Regitz-Zagrosek said. “Nevertheless, it is helpful and we are still providing it for the older drugs where this classification is available.”

Other information in this table include pre-clinical and clinical safety data.

“This was really an enormous work to put this together and I think now it’s the most reliable and the most comprehensive source on what is known of the potential of different drugs to generate harm to the mother or to the fetus,” Regitz-Zagrosek said.

Compared with women who are not pregnant, those who are do not have different indications for intervention such as those involving surgery or catheters, according to the presentation. Some exceptions are severe asymptomatic mitral stenosis and severe aortic dilation.

Women with suspected or known congenital or acquired CV and aortic disease are recommended to undergo pre-pregnancy risk assessment and counseling. Though this, the modified WHO classification of maternal risk should be used to assess women with cardiac disease of childbearing age and after conception.

The recommendations also suggest that a multidisciplinary pregnancy heart team should treat women at high risk.

“It doesn’t imply that in every hospital, you should have this pregnancy heart team, but you can also consult on the distance level,” Jolien W. Roos-Hesselink, MD, PhD, of the department of cardiology at Erasmus University Rotterdam in the Netherlands, said during the presentation. “Just contact such a center where you know that there is expertise in pregnancy and cardiac disease and try to discuss this patient timely, so you can prevent the complications to occur and to make a good pregnancy plan.”

A pregnancy heart team should also be consulted when deciding upon a valve prosthesis in women who are thinking about getting pregnant.

Pre-pregnancy counseling should include maternal risk for complications during pregnancy, possible irreversible effects, fetal risk, genetic aspects, medication use and long-term prognosis of the mother, according to the presentation.

The pregnancy heart team should at least have a cardiologist, an obstetrician/gynecologist and an anesthetist.

“They have to have experience in pregnancy and heart disease,” Roos-Hesselink said.

When necessary, other specialists should join the team, including a hematologist, a cardiothoracic surgeon and an internal medicine specialist.

According to the modified WHO 4, women who should be counselled against pregnancy include those with Fontan operation and additional comorbidities including arrhythmias, ventricular dysfunction or valve regurgitation. Other conditions include those such as pulmonary arterial hypertension, severe systemic ventricular dysfunction, severe re-coarctation, systemic right ventricle with moderate or severely decreased ventricular function, severe aortic dilatation or history of aortic dissection and severe mitral stenosis even when asymptomatic.

During pregnancy, women with congenital or other genetic heart disease should undergo a fetal echocardiogram between 19 weeks and 22 weeks of pregnancy. Between 20 weeks and 30 weeks, a delivery plan should be made which focuses on induction, labor management, delivery and postpartum surveillance. If anticoagulation is necessary for a pregnant woman, low molecular weight heparin should only be used if the woman undergoes weekly monitoring of anti-Xa levels.

A new recommendation in this guideline is that pregnant women with cardiac disease should have induced labor at 40 weeks of gestation.

“This will have a clinical impact, but we think that there are no advantages for the mother and no disadvantages for the baby,” Roos-Hesselink said.

Vaginal delivery is preferred for most patients, but caesarean section may be indicated for those with aggressive aortic pathology, pre-term labor in patients on oral anticoagulants, acute intractable HF and severe forms of pulmonary hypertension. In addition, endocarditis prophylaxis is not recommended for women. Postpartum monitoring is also critical, according to the presentation.

“The period after delivery is an important period often neglected a little bit,” Roos-Hesselink said. “Many complications occur in the first 3 to 5 days after delivery.”– by Darlene Dobkowski

References:

Regitz-Zagrosek V, et al. ESC Clinical Practice Guidelines. Presented at: European Society of Cardiology Congress; Aug. 25-29, 2018; Munich.

Regitz-Zagrosek V, et al. Eur Heart J. 2018;doi:10.1093/eurheartj/ehy340.

Disclosures : Regitz-Zagrosek reports she has financial relationships with Berlin Chemie AG, Cognomed, Novartis, Pfizer, Saarländischer Hausärzteverband, Verband deutscher Unternehmerinnen, Vinzenz von Paul Kliniken gGmbH and Zahnmedizinisches Fortbildungszentrum. Roos-Hesselink reports no relevant financial disclosures. Please see the guideline for all other authors’ relevant financial disclosures.

    Perspective
    Margo Minissian

    Margo Minissian

    The current guidelines are based on the previously published ESC guidelines on the management of CVD during pregnancy, the literature found in a systematic search from 2011–16 in the National Institutes of Health database (PubMed) and on recent publications and recommendations from the American Heart Association and the American College of Cardiology. Therefore, these important recommendations can help provide guidance for European and U.S. populations until an improved approach to systematizing registries and initiating prospective trials can be completed internationally.

    Figure 1 in the European Heart Journal publication provides the reader with important comparisons to the 2011 guidelines showing updates along with new recommendations and new concepts nicely presented for readers.

    These new concepts include:

    • Enforcing modified WHO classification of maternal risk.
    • Introduction of the pregnancy heart team.
    • More attention for assisted reproductive therapy.
    • Discussion of the use of bromocriptine in postpartum cardiomyopathy.
    • Introduction of specific levels of surveillance based on low/medium/high risk for arrhythmia with hemodynamic compromise at delivery.
    • New information on pharmacokinetics in pregnancy, more detailed information on pharmacodynamics in animal experiments on all drugs (Supplementary Data)
    • Perimortem caesarean section is discussed.
    • Advice on contraception and the termination of pregnancy in women with cardiac disease is now provided.

    The U.S. has moved towards a “pregnancy heart team” concept, and this is currently a hot topic amongst maternal fetal medicine and cardiovascular teams nationally.

    There are multiple clinical implications discussed within this guideline. Most notably are the modified WHO classification of maternal CV risk, which is a table that will help streamline risk stratification based on CV etiology. This important tool will help the CV specialist present level of risks associated with her CV condition and will help both the clinician and patient make informed decisions.

    Towards the end of the document, there is a helpful “what to do and not do” recommendations from the guidelines, which can be a quick resource for the busy clinician.

    Regitz-Zagrosek and colleagues nicely answer this question within their publication: “Because prospective or randomized studies are frequently absent during pregnancy, recommendations in these guidelines mostly correspond to evidence level C. Therefore, registries and prospective studies are urgently needed to improve current knowledge.” We need to encourage the collection of data from around the globe to better inform our decisions for women with CVD during pregnancy.

    In addition to CVD during pregnancy, it is important for women to know their pregnancy history and for clinicians to appropriately document history of adverse pregnancy outcomes. Women who experience hypertension during pregnancy, gestational diabetes, preeclampsia and preterm delivery are at increased risk of future CVD. Managing risk factors can help alter their trajectory towards a healthier future.

    • Margo Minissian, PhD, ACNP, CLS, AACC, FAHA
    • Nurse Scientist
      Cardiology Nurse Practitioner
      Clinical Lipid Specialist
      Cedars-Sinai Heart Institute
      Women’s Heart Center

    Disclosures: Minissian reports no relevant financial disclosures.

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