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Pharmacotherapy for cardiovascular disease in pregnancy

Session presentations
Cardiovascular Pharmacology and Pharmacotherapy

Definition of hypertension during pregnancy includes specific conditions such as pre-eclampsia and eclampsia. Hypertension occurs in 6-8% of all pregnancies, and this number will increase with the increasing age of pregnant women. 12.3% of all pregnancy-related maternal deaths are caused by hypertension. In general, pregnant women with hypertension should be treated for better maternal and fetal outcome. The only exception that could be pointed out is if treatment is needed in pregnant women with mild hypertension (systolic BP<150mmHg), in this population there is not significant maternal benefit with an increase of fetal risk caused by impaired utero-placental perfusion and fetal exposure to antihypertensive drugs. Which drug should be used? The agents should have been used for a long time in clinical practice; they should be effective in blood pressure control; they need to be relatively well tolerated and the side effect profile should be low. There are current trials ongoing to compare different drugs and identify the best strategy. Until we know the results, the agents with a better risk profile in mother and fetus are: methyldopa, calcium-channel antagonists, (e.g. nifedipine and verapamil). With labetalol and diuretics, close monitoring is needed. ACE inhibitors, ARBs and RAAS inhibitors are contraindicated in pregnancy.

Heart Failure
0.2-3% of pregnancies in western countries are complicated by CV diseases. The prevalence of Ischaemic Heart Disease will increase due to the advanced age of pregnant women. The cause of myocardiopathy is 50% idiopathic and 9% myocarditis. The mechanism of heart failure is the impact of pregnancy-related changes in cardiovascular physiology in patients with impaired cardiac function. The management of heart failure in pregnant women does not differ from heart failure treatment in non-pregnant women. However, the main steps are: 1) Risk stratification for developing heart failure; 2) A multidisciplinary approach; 3) Drug alternatives (avoid ACEi, ARBs, RAASi), 4) anticoagulation (when there is an associated condition such as atrial fibrillation); 5) Frequent surveillance; 6) to anticipate problems (the need for an early delivery). Peripartum myocardiopathy is a specific condition of pregnant women. Clinical presentation is heart failure (pulmonary congestion or low output heart failure). 50% of cases recovered, 10% died within 2 years and 0-1% need a heart transplant.

60% of arrhythmias during pregnancy are sinus tachycardia and 14% are supraventricular arrhythmias (SVA). It is important to evaluate the potential precipitating factors (e.g tobacco, caffeine, electrolyte imbalance, anaemia…). Most of the rhythm disturbances during pregnancy don’t need treatment if they are well tolerated and precipitating factors are corrected. If antiarrhythmic therapy is needed, most recommendations are class C (never tested in clinical trials in pregnant women): Adenosine can be used to reverse SVA. Invasive procedures should be avoided during pregnancy unless necessary, due to fetal radiation.

There is an increase in thrombotic risk in pregnancy because of two factors: a) pregnancy is a hypercoagulable state, b) normal compression of the iliac vein. The risk increases: arterial thromboembolism x 3-4; venous thromboembolism x 4-5; venous thromboembolism post-partum x 20; prosthetic valve thrombosis 7-23, above all in first generation cardiac prostheses. ESC guidelines express the level of recommendation to prevent thrombosis with low bleeding risk although counselling with the mother is important, in the two most common indications for anticoagulation during pregnacy, namely Atrial Fibrillation and metallic cardiac prosthesis. There is not an A category recommendation for antithrombotics in pregnancy. Aspirin is a class B recommendation and warfarin is a class D recommendation. There is a continuous need to balance the risk of thromboembolic events in the mother with the bleeding risk together with the teratogenic effect of the potential agent on the fetus.




Pharmacotherapy for cardiovascular disease in pregnancy

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.