One of the most prevalent types of heart failure during pregnancy, heart failure with preserved ejection fraction and pregnancy (HFpEF), is associated with increased risk of hospitalization and adverse pregnancy outcomes. In this video, Dr. Oliveros covers:
Risk factors for HFpEF, and how to manage during pregnancy and postpartum
Pathophysiology of peripartum cardiomyopathy and when patients are at greatest risk
Which heart failure medications are safe during pregnancy and lactation
Please also see Dr. Oliveros's other two video presentations on treating cardiovascular issues during pregnancy, including:”
Multidisciplinary Group Approach to Managing Pregnant Patients with Cardiovascular Disease
Heart Failure During Pregnancy
My name is Estefania Oliveros and I'm an Assistant Professor of Medicine at Temple University Hospital. One of the things that we're gonna discuss now is heart failure with preserved injection fraction and pregnancy. This is probably one of the most prevalent um types of heart failure during pregnancy. You will see patients with sleep apnea, hypertensive disorders of pregnancy and gestational diabetes, iron deficiency anemia, precipitating increase in heart rate and oxidative stress. CKD related to increase in blood volume and hypertension disorders. Um chronic hypertension that is prevalent in our population with concentric hypertrophy, obesity, coronary heart disease, diabetes and obstetric conditions that can also be associated with these which are c-section, hypertensive disorders, multi and older age. Uh people, what you'll see is that there's an increase in the afterload, increase in the preload changes in the atrial contraction and lb geometry. The RV and LV interaction is very different during this period. So all of these will contribute to this path of physiology to be exacerbated. Uh during pregnancy, there will be more myocardial stiffness and tendency to have more half path and pulmonary congestion, hospitalizations related to pregnancy are increased um in groups with half by 90% per year. Chronic hypertension and hypertensive pregnancy disorders such as preeclampsia, eclampsia will drive uh all these half admissions. It's more frequent and prevalent in black individuals or older or uh people from poor or low socio economic status and it will increase 2.6 to 6.4 times uh any adverse pregnancy outcomes. Other things that are important are prepartum cardiomyopathy, prepartum cardiomyopathy has a specific definition is non ischemic cardiomyopathy with reduced ejection fraction, less than 45%. And your risks are very specific. Um black race prelay hypertension. Most multigalactic with prepartum cardiomyopathy. It happens by the end of your pregnancy. It happens specifically one month before delivery until five months after delivery. That's the specific frame. The evolution of uh reported mortality. Part of chiro has ranged from 1971 until the most recent um registry from 2015, from 1.3 to almost uh 48%. As you have can see in this graph or in this table, there's actually a decrease over time because of the introduction of, of, of uh heart failure uh and guideline directed uh medical therapy. But there's nothing specific as of now to treat people with party partum cardiomyopathy. The pathophysiology of prepartum cardio is very specific. What happens is that there's a change um made in your peter with changes in your prolactin that precipitate changes in your micro RN A and the endothelial dysfunction and things that are happening at the level of your placenta with vegf, that precipitates cardiac myoid apoptosis and death. There's also a consideration that there can be sarcomere gene mutations uh that can affect um this pathway as well. So let's uh talk about a patient. So you have a 37 year old um female black G four P, 2, 38 week pregnant. Uh Her LVF is 35%. 1 is the Island directed medical therapy that you will decide to put her on diuretics, frozen nitro pros or or beta blockers. Beta blockers should be your next step for guideline directed medical therapy. So the principles in management are gonna be two while a patient is pregnant, you want use uh things like diuretics, betablockers, hydrALAZINE, nitrates or IB nro and dioxin. You wanna avoid as much as possible. I bro proc side and after delivery, you can use diuretics. Things that are safe during lactation would be an April, not all ace inhibitors, but that one in particular beta blockers can be used in Aldo and sec. Um A and I are a possibility as well although um I has not been studied uh during uh lactation. This is a very interesting publication of uh of cardiovascular medications in pregnancies. And I think it's very useful uh to have as a resource and as a tool. Um You see how most common um medical problems have been described, arrhythmic, heart failure, antiqua and antipla the thrombolytics hypertension ph and things that are overall contra indicated in pregnancy and it divides them by first column, things that are saved during pregnancy. Second column, FDA C category and third column is the ones that are uh saved during uh lactation. If we focus on the heart failure, medications, as we mentioned, melo and Carlo are things that are considered safe. You can use diuretics monitoring the amount of diuresis that you actually give during pregnancy as it can reduce amniotic fluid. You can use do dopamine and the dobutamine Lebo fat. Those are pressors in case you are presenting, having a patient presenting uh in cardiogenic shock, hydroly, uh nro are limited data same as um isosorbide dini to and metal, but they can be used. Uh There's some conflicting data during um lactation. When you look at the different registries of our part of this is very interesting because the mortality ranges from 2% to 19% being the highest in Nigeria from the USA and I A. You see a mortality of 4%. The recovery was achieved in most of them, about 72% recovery, meaning recovery of ejection fraction. And the monitoring was up to from six months to uh five years. So the same patient that you treated has delivered, she wants to know can she have another baby. So the way uh we usually think about this is in two instances if the patient has persistent LV, cystic dysfunction of less than 50% your counseling will be a little bit different. You'll tell that patient that there's 50% risk for relapse heart failure. 43% risk of persistent LV, cysto dysfunction. 50% risk of premature delivery and 80% risk of maternal death. If uh on the off chance the patient has actually improved their ejection fraction. Up to 50%. You'll see only 31% risk of uh heart failure from 50 from the other group. 14% of risk of persistent LVC. So dysfunction, 13% risk of premature delivery and 0% low risk of maternal death.
