The following question refers to Sections 11.3 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure.
The question is asked by Western Michigan University medical student and CardioNerds Intern Shivani Reddy, answered first by Johns Hopkins Osler internal medicine resident and CardioNerds Academy Fellow Dr. Justin Brilliant, and then by expert faculty Dr. Harriette Van Spall.
Dr. Van Spall is Associate Professor of Medicine, cardiologist, and Director of E-Health at McMaster University. Dr Van Spall is a Canadian Institutes of Health Research-funded clinical trialist and researcher with a focus on heart failure, health services, and health disparities.
The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance.
Ms. Augustin is a 33 y/o G1P1 woman from Haiti who seeks counseling regarding family planning as she and her husband dream of a second child. Her 1st pregnancy 12 months ago was complicated by pre-eclampsia and peripartum cardiomyopathy (LVEF 35%). Thankfully she delivered a healthy baby via C-section. She has no other past medical history and is currently on losartan 25 mg daily and metoprolol succinate 200 mg daily. She has been asymptomatic. Which of the following statements is recommended to medically optimize Ms. Augustin prior to her 2nd pregnancy?
No medical optimization or preconception planning is needed as her 1st pregnancy resulted in a healthy infant.
Discontinue losartan and metoprolol with no other needed pregnancy planning
Change her medication regimen, consider repeat TTE, and provide patient-centered counseling regarding risk of a future pregnancy
Continue losartan and metoprolol and advise against repeat pregnancy
The correct answer is C – change her medication regimen, consider repeat TTE, and provide patient-centered counseling regarding risk of a future pregnancy.
Heart failure may complicate pregnancy either secondary to an existing pre-pregnancy cardiomyopathy or as a result of peripartum cardiomyopathy. In women with history of heart failure or cardiomyopathy, including previous peripartum cardiomyopathy, patient-centered counseling regarding contraception and the risks of cardiovascular deterioration during pregnancy should be provided (Class I, LOE C-LD)
Peripartum cardiomyopathy (PPCM) is defined as systolic dysfunction, typically LVEF < 45%, often with LV dilation, occurring in late pregnancy or early postpartum with no other identifiable etiology. PPCM occurs worldwide, with the highest incidences in Haiti, Nigeria, and South Africa. Other clinical risk factors include maternal age > 30 years, African ancestry, multiparity, multigestation, preeclampsia/eclampsia, anemia, diabetes, obesity, and prolonged tocolysis.
The pathogenesis of peripartum cardiomyopathy is complex and it is likely a multifactorial process. The combination of hemodynamic changes of pregnancy, inflammation of the myocardium, hormonal changes, genetic factors, and an autoimmune response have all been proposed as possible mechanisms and these may certainly be interrelated.
While pregnancy is generally well-tolerated in women with cardiomyopathy and NYHA class I status pre-pregnancy, clinical deterioration can occur and so counseling and shared decision-making are important. In fact, the ROPAC study of pregnancy outcomes for women with structural heart disease showed that women with pre-pregnancy or previous peripartum CM had the highest mortality rate at 2.4%. Subsequent pregnancies for women with previous peripartum cardiomyopathy have been associated with further decreases in LV function, maternal death, and adverse fetal outcomes. LVEF < 50% prior to a subsequent pregnancy is the strongest prognostic determinant.
Different strategies are needed to optimize the cardiovascular health of women with a prior history of PPCM before embarking on a subsequent pregnancy including pre-conception counseling regarding risk of subsequent pregnancies, pharmacologic strategies, and a multi-disciplinary approach to expectant management.
Pre-conception counseling: can utilize cardiovascular risk tools including ZAHARA I and CARPREG II scores (which predict outcomes during pregnancy in women with prior heart disease) and obtain a baseline TTE prior to conception to inform shared decision making.
Pharmacologic strategies: in women with HF or cardiomyopathy who are
pregnant or currently planning for pregnancy, ACEi, ARB, ARNi, MRA, SGLT2i, ivabradine, and vericiguat should not be administered because of significant risks of fetal harm (Class 3: Harm, LOE C-LD). Beta blockers (preferably metoprolol), hydralazine, and nitrates are considered acceptable during pregnancy, when guided by multidisciplinary shared decision-making regarding benefits and potential risks. Diuretic dosing should be discussed (if applicable) to minimize the risk of placental hypoperfusion. A repeat TTE should be performed 3 months following changes in heart failure medicine regimen. Of note, postpartum women who breastfeed can start an ACEi (enalapril or captopril are preferred), and metoprolol remains the preferred beta blocker.
Multidisciplinary care may include consultations with genetics, gynecology, and maternal-fetal medicine teams, as appropriate to the outcome of shared decision making. During pregnancy, for women with decompensated HF or evidence of hemodynamic instability antepartum, delivery planning will include obstetrics and maternal-fetal medicine, cardiac anesthesia, cardiology, and neonatology teams.
Therefore, answer choice C is correct because pre-conception counseling is essential to guide pertinent discussions on risk stratification prior to subsequent pregnancies. Additionally, her medications need to be modified by discontinuing her ARB prior to conception.
Choice A is incorrect because she is high risk for worsening cardiomyopathy and repeat preeclampsia in her next pregnancy.
Choice B is incorrect because shared decision making and risk stratification prior to 2nd pregnancy are essential.
Choice D is incorrect because, although she is at high risk for complications including worsening cardiomyopathy, preeclampsia/eclampsia, and neonatal demise, repeat pregnancy is not absolutely contraindicated and should be an informed decision after appropriate education within the construct of a multidisciplinary team.
In summary, when a patient with history of peripartum cardiomyopathy is planning on a repeat pregnancy, patient-centered counseling regarding risks and management strategies should be provided with guidance from a multidisciplinary team and medications should be adjusted to balance GDMT for heart failure against risks to fetal development.
Section 11.3, Table 30