Contemporary Management of Cardiomyopathy and Heart Failure in Pregnancy

Abstract

Cardiovascular disease is the primary cause of pregnancy-related mortality and morbidity in the United States, and maternal mortality has increased over the last decade. Pregnancy and the postpartum period are associated with significant vascular, metabolic, and physiologic adaptations that can unmask new heart failure or exacerbate heart failure symptoms in women with known underlying cardiomyopathy. There are unique management considerations for heart failure in women throughout pregnancy, and it is imperative that clinicians caring for pregnant women understand these important principles. Early involvement of multidisciplinary cardio-obstetrics teams is key to optimizing maternal and fetal outcomes. In this review, we discuss the unique challenges and opportunities in the diagnosis of heart failure in pregnancy, management principles along the continuum of pregnancy, and the safety of heart failure therapies during and after pregnancy.

Keywords: Cardio-obstetrics; Cardiomyopathy; Heart failure; Peripartum cardiomyopathy; Pregnancy.

Fig. 1

Assessment of worsening symptoms or acute heart failure in pregnancy. CBC complete blood count, CMP comprehensive metabolic panel, CXR chest X-ray, ECG electrocardiogram, GDMT guideline-directed medical therapy, HR heart rate, NTproBNP N-terminal-pro B-type natriuretic peptide, hsTn high-sensitivity troponin, PPCM peripartum cardiomyopathy, RHC right heart catheterization, RR respiratory rate, SBP systolic blood pressure, SCvO2 central mixed venous oxygen saturation, SpO2 oxygen saturation, TTE transthoracic echocardiography

Fig. 2

Risk stratification tools and models for the assessment of maternal cardiac morbidity and mortality during pregnancy: Cardiac Disease in Pregnancy Study (CARPREG) II [33], modified World Health Organization (WHO) [34], and ZAHARA (Zwangerschap bij Aangeboren HARtAfwijkingen [Pregnancy in Women with Congenital Heart Disease]) [35]. AS aortic stenosis, ASD atrial septal defect, AV atrioventricular, HCM hypertrophic cardiomyopathy, LV left ventricle, LVEF left ventricular ejection fraction, LVOTO left ventricular outflow tract obstruction, MS mitral stenosis, MVP mitral valve prolapse, NYHA New York Heart Association, PAC premature atrial contraction, PAH pulmonary arterial hypertension, PDA patent ductus arteriosus, PPCM peripartum cardiomyopathy, PS pulmonic stenosis, PVC premature ventricular contraction, RV right ventricle, TAPVR total anomalous pulmonary vein return, TOF tetralogy of Fallot, VSD ventricular septal defect

Fig. 3

Key principles in the management of women with heart failure across the continuum of pregnancy. GDMT guideline-directed medical therapy, PAH pulmonary arterial hypertension, TTE transthoracic echocardiography, VKAs vitamin K antagonists