HEART FAILURE IN PREGNANCY Afshan Hameed, MD, FACOG, FACC Assistant Professor, Maternal Fetal Medicine & Cardiology University of California, Irvine M...
HEART FAILURE IN PREGNANCY Afshan Hameed, MD, FACOG, FACC Assistant Professor, Maternal Fetal Medicine & Cardiology University of California, Irvine March of Dimes 3-7-11
3 million women age 18-44 in the US have heart disease ~ 1% of pregnant women
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Pregnancy Related Deaths North Carolina 1996-99 Cause of Death Cardiomyopathy
% of All Deaths 21%
Hemorrhage
14
PIH
10
CVA
9
Chronic condition
9
AFE
7
Infection
7
Pulmonary embolism
6
Berg CJ et al. Obstet Gynecol 2005
Important cause of maternal morbidity and mortality
oWhat causes it? The basics of cardiac physiology Underlying cardiac disease
Pregnancy induced cardiac failure oCan we prevent?
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Structural Cardiac Disease
Pregnancy induced cardiac dysfunction
Heart Failure in Pregnancy Arrhythmias
Other
oWhat causes it? The basics of cardiac physiology Underlying cardiac disease
Pregnancy induced cardiac failure oCan we prevent?
-Caseo24 yo Hispanic female G1 @ 33 wks oProgressive dyspnea for 3 months oSOB and productive cough oCXR: Bilateral infiltrates oEKG: Sinus tachycardia oTreated for pneumonia x 5 days oNo improvement
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SYMPTOMS OF MITRAL STENOSIS DYSPNEA - Increased left atrial pressure FATIGUE - Fixed cardiac output ANKLE EDEMA - Right heart failure
Cardiac Risk in Rheumatic Mitral Stenosis
Silversides et al AJC 2003;91:1382
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Aortic Stenosis oRare in pregnancy oPregnancy contraindicated if symptomatic
SYMPTOMS OF AORTIC STENOSIS Chest pain Dizziness/ Syncope Dyspnea
Aortic Stenosis in Pregnancy
-Caseo 36 yo Hispanic female G2 P1 at 16 3/7 wks o NYHA functional class II o EKG: Normal sinus rhythm o Echocardiogram:
EF 66%, Bicuspid aortic valve, AVA 0.9 cm2 , Peak gradient 64 mm Hg
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Valvular Disease in Pregnancy
-Case-
o Symptoms of CHF at ~ 27 weeks
o Percutaneous Aortic balloon valvuloplasty @ 28 weeks – AVA 1.2 – Peak gradient 40 mm Hg
o Delivery at 36 weeks after fetal lung maturity
Aortic Stenosis and Pregnancy
Maternal Outcome 100%
100%
Mild Moderate
50%
Severe
43%
All
33% 25% 8% 0%
0%
0%
CHF
0% Arrhythmias
Hameed et al JACC 2001;37:893-899
oWhat causes it? The basics of cardiac physiology Underlying cardiac disease
Pregnancy induced cardiac failure oCan we prevent?
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Cardiomyopathy
Case # 1 o 34 year old AA gravida 1 @ 20 weeks o Pregnancy complicated by hypercalcemia, pancreatitis, parathyroidectomy o Uncomplicated course thereafter o Normal delivery at 40 weeks, male infant 3450 gm with Apgars of 9 and 9
……….. Case #1 o Presented with shortness of breath and cough 7 days after delivery o CXR: bilateral alveolar infiltrates o Echo: Global hypokinesis with EF 35% No wall motion or valvular abnormality
o Treatment: Loop diuretics, ACE inhibitors, beta blockers, digoxin
……….. Case #1
oFollow up at 3 months
oNYHA functional class I oEcho: Normal left ventricular function EF 55%
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Peripartum Cardiomyopathy (PPCM)
What is PPCM? An idiopathic dilated CMP presenting in the 2nd or 3rd trimester of pregnancy or within several months postpartum associated with depressed LV systolic function
What is PPCM? o Development of HF in the last month of pregnancy or within 5 months of delivery o Absence of identifiable cause for HF o Absence of recognizable heart disease prior to the last month of pregnancy o Left ventricular systolic dysfunction demonstrated by echocardiography NIH Workshop Recommendations and Review 1997, Pearson et al, JAMA 2000; 283:1183
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PPCM – Time of Diagnosis Elkayam et al. Circulation 2005;111:2050 75
Number of patients
Early Traditional 50
N=123 25
0
< 27
28-32
33-36
37-40
1
2
Weeks
3
4
5
Months PP DELIVERY
Incidence Incidence of peripartum cardiomyopathy in various populations STUDY
STUDY POPULATION LOCATION
INCIDENCE OF PERIPARTUM CARDIOMYOPATHY
Davidson and Parry [] Meadows [] Woolford [] Cunningham et al. []
Nigeria (Hausa tribe) United States United States United States
1/100 deliveries 1/1300 live births 1/4000 live births 1/15,150 deliveries
Recent surveys in the US and Canada found a ratio of 1~ 2300 live births (~1300 cases/year) Higher incidence reported in South Africa (1:1000) and in Haiti (1:300 ) Circ 2004;110:III 520
Peripartum Cardiomyopathy
Risk Factors o The exact cause of PPCM remains unknown
Age >30 Poor nutrition - ?Selenium deficiency African American Multiple gestation Long term tocolytic therapy History of preeclampsia Immunological mechanisms / Myocarditis Stress-activated proinflammatory cytokines (TNF- or interleukin 1) Abnormalities of relaxin, prolactin
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Who is at Risk?
PREGNANCY ASSOCIATED CARDIOMYOPATHY
Index Pregnancy 50% 42% 40%
n=123 30%
20%
17%
17% 14% 10%
10%
0% 1st
2nd
3rd
4th
5th
Elkayam et al. Circulation 2005;111:2050
PPCMP
How Does it Present? oHeart failure oArrhythmias +/- HF oThromboembolism oAsymptomatic LV dysfunction
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Outcome of PPCM 123 Patients Recovery EF > 50%
Persistent LV dysfxn
(at last f/u)
(at last f/u)
54%
41%
Cardiac Transplantation
4% Death
9% (2 pts died post transplant)
Elkayam et al. Circulation 2005;111:2050
Predictors of LV dysfunction? o Severe of LV dilatation and systolic dysfunction @ diagnosis
o Evidence for myocardial cell damage (Troponin T level >0.04 ng/ml within 2 weeks of diagnosis) (Hu CL et al Heart 2007;93:488-90)
o Lack of recovery at 2-6 months (Elkayam et al. Circulation 2005;111:2050 & Amos et al AHJ 2006 ;152:509)
