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Guzmán-Delgado NE, Velázquez-Sotelo CE, Fernández-Gómez MJ, González-Barrera LG, Muñiz-García A, Sánchez-Sotelo VM, Carranza-Rosales P, Hernández-Juárez A, Morán-Martínez J, Martínez-Gaytan V. Adverse cardiovascular, obstetric and perinatal events during pregnancy and puerperium in patients with heart disease. Rev Clin Esp 2024; 224:337-345. [PMID: 38697610 DOI: 10.1016/j.rceng.2024.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 04/05/2024] [Indexed: 05/05/2024]
Abstract
BACKGROUND AND OBJECTIVES cardiovascular changes during pregnancy carry greater risk in heart disease. We analyze cardiovascular, obstetric and perinatal adverse effects associated with congenital and acquired heart disease during pregnancy and postpartum. MATERIALS AND METHODS Cross-sectional and retrospective study, which included the 2017-2023 registry of pregnant or postpartum patients hospitalised with diagnosis of congenital or acquired heart disease. Adverse events (heart failure, stroke, acute pulmonary edema, maternal death, obstetric haemorrhage, prematurity and perinatal death) were compared with the clinical variables and the implemented treatment. RESULTS 112 patients with a median age of 28 years (range 15-44) were included. Short circuits predominated 28 (25%). Thirty-six patients (32%) were classified in class IV of the modified WHO scale for maternal cardiovascular risk. Heart failure occurred in 39 (34.8%), acute lung edema 12 (10.7%), stroke 2 (1.8%), maternal death 5 (4.5%), obstetric haemorrhage 4 (3.6%), prematurity 50 (44.5%) and perinatal death 6 (5.4%). Shunts were associated with prematurity (adjusted odds ratio 4; 95% CI: 1.5-10, p = 0.006). Peripartum cardiomyopathy represented higher risk of pulmonary edema (adjusted OR 34; 95% CI: 6-194, p = 0.001) and heart failure (adjusted OR 16; 95% CI: 3-84, p = 0.001). An increased risk of obstetric haemorrhage was observed in patients with prosthetic valves (adjusted OR 30; 95% CI: 1.5-616, p = 0.025) and with the use of acetylsalicylic acid (adjusted OR 14; 95% CI: 1.2-16, p = 0.030). Furthermore, the latter was associated with perinatal death (adjusted OR 9; 95% CI: 1.4-68, p = 0.021). CONCLUSIONS severe complications were found during pregnancy and postpartum in patients with heart disease, which is why preconception evaluation and close surveillance are vital.
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Affiliation(s)
- N E Guzmán-Delgado
- División de Investigación en Salud, Unidad Médica de Alta Especialidad, Hospital de Cardiología No. 34, "Dr. Alfonso J. Treviño" del Centro Médico Nacional del Noreste, Instituto Mexicano del Seguro Social, Monterrey, Nuevo León, Mexico; Programa de Posgrado en Especialidades Médicas, Universidad de Monterrey. San Pedro Garza, García, Nuevo León, Mexico
| | - C E Velázquez-Sotelo
- Departamento de Cardiología, Unidad Médica de Alta Especialidad, Hospital de Cardiología No. 34, "Dr. Alfonso J. Treviño Treviño" del Centro Médico Nacional del Noreste, Instituto Mexicano del Seguro Social, Monterrey, Nuevo León, Mexico; Programa de Posgrado en Especialidades Médicas, Universidad de Monterrey. San Pedro Garza, García, Nuevo León, Mexico.
| | - M J Fernández-Gómez
- División de Investigación en Salud, Unidad Médica de Alta Especialidad, Hospital de Cardiología No. 34, "Dr. Alfonso J. Treviño" del Centro Médico Nacional del Noreste, Instituto Mexicano del Seguro Social, Monterrey, Nuevo León, Mexico
| | - L G González-Barrera
- Departamento de Cardiología, Unidad Médica de Alta Especialidad, Hospital de Cardiología No. 34, "Dr. Alfonso J. Treviño Treviño" del Centro Médico Nacional del Noreste, Instituto Mexicano del Seguro Social, Monterrey, Nuevo León, Mexico
| | - A Muñiz-García
- Departamento de Cardiología, Unidad Médica de Alta Especialidad, Hospital de Cardiología No. 34, "Dr. Alfonso J. Treviño Treviño" del Centro Médico Nacional del Noreste, Instituto Mexicano del Seguro Social, Monterrey, Nuevo León, Mexico; Programa de Posgrado en Especialidades Médicas, Universidad de Monterrey. San Pedro Garza, García, Nuevo León, Mexico
| | - V M Sánchez-Sotelo
- Departamento de Cirugía Cardiotorácica, Unidad Médica de Alta Especialidad, Hospital de Cardiología No. 34, "Dr. Alfonso J. Treviño Treviño" del Centro Médico Nacional del Noreste, Instituto Mexicano del Seguro Social, Monterrey, Nuevo León, Mexico
| | - P Carranza-Rosales
- Centro de investigación Biomédica del Noreste. Instituto Mexicano del Seguro Social. Monterrey, Nuevo León, Mexico
| | - A Hernández-Juárez
- Departamento de Cardiología, Unidad Médica de Alta Especialidad, Hospital de Cardiología No. 34, "Dr. Alfonso J. Treviño Treviño" del Centro Médico Nacional del Noreste, Instituto Mexicano del Seguro Social, Monterrey, Nuevo León, Mexico; Programa de Posgrado en Especialidades Médicas, Universidad de Monterrey. San Pedro Garza, García, Nuevo León, Mexico
| | - J Morán-Martínez
- Departamento de Biología Celular y Ultraestructura, Facultad de Medicina, Universidad Autónoma de Coahuila unidad Torreón, Torreón, Coahuila, Mexico
| | - V Martínez-Gaytan
- División de Investigación en Salud, Unidad Médica de Alta Especialidad de Gineco Obstetricia No.23, Dr. Ignacio Morones Prieto, Instituto Mexicano del Seguro Social, Monterrey, Nuevo León, Mexico
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Abubakar M, Saleem A, Hajjaj M, Faiz H, Pragya A, Jamil R, Salim SS, Lateef IK, Singla D, Ramar R, Damara I, Shahid L. Sex-specific differences in risk factors, comorbidities, diagnostic challenges, optimal management, and prognostic outcomes of heart failure with preserved ejection fraction: A comprehensive literature review. Heart Fail Rev 2024; 29:235-256. [PMID: 37996694 DOI: 10.1007/s10741-023-10369-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/06/2023] [Indexed: 11/25/2023]
Abstract
Due to hormonal variations, heart failure with preserved ejection fraction (HFpEF) remains prevalent in women and affects almost half of the heart failure (HF) patients. Given the yearly death rate of 10-30% and the unavailability of medications targeting HFpEF, the need arises for a better understanding of the fundamental mechanisms of this syndrome. This comprehensive review explores sex-specific differences in traditional risk factors; female-specific factors that may impact HFpEF development and response to therapy, including variations in hormone levels that may occur pre- and post-menopausal or during pregnancy; and disparities in comorbidities, clinical presentation, and diagnostic challenges. Lastly, the review addresses prognostic outcomes, noting that women with HFpEF have a poor quality of life but a higher survival rate. It also discusses novel biomarkers and precision medicine, emphasizing their potential to improve early detection and personalized treatment.
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Affiliation(s)
- Muhammad Abubakar
- Department of Internal Medicine, Ameer-Ud-Din Medical College, Lahore General Hospital, 6 Birdwood Road, Jinnah Town, Lahore, Punjab, 54000, Pakistan.
| | - Ayesha Saleem
- Department of Internal Medicine, Jinnah Hospital, Lahore, Punjab, Pakistan
| | - Mohsin Hajjaj
- Department of Internal Medicine, Jinnah Hospital, Lahore, Punjab, Pakistan
| | - Haseeb Faiz
- Department of Internal Medicine, Jinnah Hospital, Lahore, Punjab, Pakistan
| | - Aastha Pragya
- Department of Internal Medicine, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India
| | - Rosheen Jamil
- Department of Internal Medicine, Mayo Hospital, Lahore, Punjab, Pakistan
| | - Siffat Saima Salim
- Department of Surgery, Holy Family Red Crescent Medical College Hospital, Dhaka, Bangladesh
| | | | - Deepak Singla
- Department of Internal Medicine, Government Medical College, Patiala, Punjab, India
| | - Rajasekar Ramar
- Department of Internal Medicine, Rajah Muthiah Medical College, Chidambaram, Tamil Nadu, India
| | - Ivan Damara
- Department of Internal Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Laraib Shahid
- Department of Dermatology, Lahore General Hospital, Lahore, Punjab, Pakistan
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Giorgione V, Cauldwell M, Thilaganathan B. Pre-eclampsia and Cardiovascular Disease: From Pregnancy to Postpartum. Eur Cardiol 2023; 18:e42. [PMID: 37456771 PMCID: PMC10345941 DOI: 10.15420/ecr.2022.56] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 01/02/2022] [Indexed: 07/18/2023] Open
Abstract
Hypertensive disorders of pregnancy (HDP) complicate approximately 10% of pregnancies. In addition to multiorgan manifestations related to endothelial dysfunction, HDP confers an increased risk of cardiovascular disease during delivery hospitalisation, such as heart failure, pulmonary oedema, acute MI and cerebrovascular events. However, the cardiovascular legacy of HDP extends beyond birth since these women are significantly more likely to develop cardiovascular risk factors in the immediate postnatal period and major cardiovascular disease in the long term. The main mediator of cardiovascular disease in women with a history of HDP is chronic hypertension, followed by obesity, hypercholesterolaemia and diabetes. Therefore, optimising blood pressure levels from the immediate postpartum period until the first months postnatally could have beneficial effects on the development of hypertension and improve long-term cardiovascular health. Peripartum screening based on maternal demographic, and clinical and echocardiographic data could help clinicians identify women with HDP at highest risk of developing postpartum hypertension who would benefit from targeted primary cardiovascular prevention.
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Affiliation(s)
- Veronica Giorgione
- Molecular and Clinical Sciences Research Institute, St. George's University of LondonLondon, UK
- Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation TrustLondon, UK
| | - Matthew Cauldwell
- Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation TrustLondon, UK
| | - Basky Thilaganathan
- Molecular and Clinical Sciences Research Institute, St. George's University of LondonLondon, UK
- Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation TrustLondon, UK
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Alghamdi N, Alqahani S, Allehyani L, Alosaimi H, Almutairi W, Alobaid S, Albackr HB, Aldakhil L, Alotaibi GS, Alqahtani FH. The Safety and Efficacy of Low-Molecular-Weight Heparin in Pregnant Women With Rheumatic Heart Disease and Valves Replacement. Cureus 2022; 14:e23052. [PMID: 35464573 PMCID: PMC9001812 DOI: 10.7759/cureus.23052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2022] [Indexed: 11/30/2022] Open
Abstract
Background: In patients with rheumatic heart disease (RHD) and prosthetic valve replacement, the risk of thromboembolic complications is the highest during and immediately after pregnancy. Therapeutic anticoagulation during this period is crucial to minimize the risk of thromboembolic complications. The use of low-molecular-weight heparin (LMWH) remains an off-label indication. The type of anticoagulants used, dosing regimens, target anti-Xa levels, and frequency of anti-Xa monitoring are highly variable in the pregnant population and have been derived from pilots, observational studies, and empirical evidence. Herein, in a real-world setting, we sought to examine the efficacy and safety of variable anticoagulation options with a focus on LMWH in the management of RHD-related valvular disease in pregnant women. Methods: This study is a retrospective study conducted at a large university-affiliated tertiary care center (King Saud University Medical City) between January 2011 and February 2020. All pregnant women with RHD who had heart valve replacements were reviewed. Patient data were extracted for demographic information, baseline characteristics, anticoagulation type, and primary outcomes. Primary endpoints were thromboembolic events, hemorrhagic complications, and fetal outcomes. Results: A total of 744 pregnancies in 149 women were identified. The mean age ± SD of the women was 43.8 ± 12 years. A total of 86 women (58%) were on the LMWH regimen, 35 women (23%) were on LMWH and warfarin regimen, and 28 women (19%) were on unfractionated heparin (UFH) and warfarin regimen. Overall, thromboembolic events developed in five (0.7%) pregnancies. Of those, two were in the LMWH group, two were in the LMWH and warfarin group, and one was in the UFH and warfarin group. In addition, significant hemorrhagic complications occurred in five pregnancies. Of these, two occurred in the LMWH group, two in the LMWH and warfarin group, and one in the UFH and warfarin group. No adverse maternal and fetal outcomes were noted. Conclusion: This study presents the largest retrospective study of variable anticoagulation options in pregnant women with RHD and prosthetic valve replacement. LMWH is both safe and effective in preventing major thromboembolic complications compared to other forms of anticoagulation used during pregnancy.
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Johny D, Subramanyam K, Shivanand S, Rajamony V. Percutaneous balloon pulmonary valvuloplasty in a pregnant woman with severe pulmonary valve restenosis. BMJ Case Rep 2021; 14:e246368. [PMID: 34764125 PMCID: PMC8587384 DOI: 10.1136/bcr-2021-246368] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2021] [Indexed: 11/03/2022] Open
Abstract
A 34-year-old woman, a known case of valvular heart disease, post balloon pulmonary valvuloplasty done 8 years ago during her first pregnancy, presented with progressive exertional breathlessness with New York Heart Association class III symptoms in her third trimester of pregnancy. On examination, she had features of right heart failure. ECG showed right axis deviation, right ventricular hypertrophy with strain pattern. Transthoracic echocardiography showed severe pulmonary valve stenosis, right ventricular hypertrophy, right ventricular and atrial dilatation with reduced right ventricular function. As the patient was symptomatic, she underwent percutaneous balloon pulmonary valvuloplasty. The procedure was successful with a significant reduction in the pulmonary valve gradient and the patient was discharged in stable condition with reduced symptoms. The timely intervention of the valvular stenotic lesion in pregnancy reduces the mortality risk to both the mother and the fetus.
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Affiliation(s)
- Dilip Johny
- Department of Cardiology, KS Hegde Medical Academy, Mangalore, India
| | | | - Sanjana Shivanand
- Department of General Medicine, KS Hegde Medical Academy, Mangalore, India
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Jayasooriya G, Silversides C, Raghavan G, Balki M. Anesthetic management of women with heart failure during pregnancy: a retrospective cohort study. Int J Obstet Anesth 2020; 44:40-50. [PMID: 32739747 DOI: 10.1016/j.ijoa.2020.06.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 05/08/2020] [Accepted: 06/15/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND The incidence of heart failure among pregnant women with pre-existing cardiac disease is quoted as 13%, with 10% requiring hospitalization. There is limited literature on heart failure in the pregnant population. The study objective was to describe the etiology and management of women hospitalized in our institution for heart failure during pregnancy. METHODS A retrospective cohort study investigated women who presented with heart failure in pregnancy between 2004 and 2017. Hospital records were interrogated using International Classification of Diseases v10 codes for heart failure. Patient characteristics, investigations, treatment, obstetric and anesthetic management, and maternal-fetal outcome data were collected and summarized using descriptive statistics. RESULTS One-hundred-and-twenty cases (in 93 122 deliveries) were identified across the 13-year period (antepartum heart failure 51%, postpartum heart failure 49%).The most common etiologies were pre-eclampsia (28%), cardiomyopathy (22%), and valvular heart disease (18%). Cesarean delivery occurred in 76% of cases (13% because of the maternal cardiac condition). Neuraxial techniques were used for most deliveries (cesarean 83%; vaginal 90%). For cesarean delivery, titrated epidural or general anesthesia was employed in 48% and 16%, respectively. Cardiac arrest occurred in two cases (1.7%) and 44% required coronary or intensive care unit admission. CONCLUSIONS The incidence of heart failure was 0.13% (1:776 deliveries). Pre-eclampsia was the leading cause but may have been historically under-acknowledged. Anesthetic and obstetrical decisions were tailored by means of multidisciplinary input, with cesarean delivery and regional anesthesia used in the majority. The postpartum period warrants heightened attention for these patients.
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Affiliation(s)
- G Jayasooriya
- Department of Anesthesiology and Pain Medicine, Mount Sinai Hospital, University of Toronto, Canada
| | - C Silversides
- Division of Cardiology, Pregnancy and Heart Disease Program, Department of Medicine, Mount Sinai Hospital, University of Toronto, Canada
| | - G Raghavan
- Department of Anesthesiology and Pain Medicine, Mount Sinai Hospital, University of Toronto, Canada
| | - M Balki
- Department of Anesthesiology and Pain Medicine, Mount Sinai Hospital, University of Toronto, Canada; Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Canada; Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Canada.
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Regitz-Zagrosek V, Roos-Hesselink JW, Bauersachs J, Blomström-Lundqvist C, Cífková R, De Bonis M, Iung B, Johnson MR, Kintscher U, Kranke P, Lang IM, Morais J, Pieper PG, Presbitero P, Price S, Rosano GMC, Seeland U, Simoncini T, Swan L, Warnes CA. 2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy. Eur Heart J 2018; 39:3165-3241. [PMID: 30165544 DOI: 10.1093/eurheartj/ehy340] [Citation(s) in RCA: 1111] [Impact Index Per Article: 185.2] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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Epidemiological profile and obstetric outcomes of patients with peripartum congestive heart failure in Taiwan: a retrospective nationwide study. BMC Pregnancy Childbirth 2017; 17:302. [PMID: 28899350 PMCID: PMC5596930 DOI: 10.1186/s12884-017-1486-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 09/04/2017] [Indexed: 11/10/2022] Open
Abstract
Background During pregnancy, the hyperdynamic physiology of circulation can exacerbate many cardiovascular disorders. Congestive heart failure (CHF) usually occurs during late pregnancy, which is significantly associated with a high level of maternal and neonatal morbidities and mortalities. The profile of women who develop peripartum CHF (PCHF) is unknown. We investigated the epidemiological profiles of PCHF. Methods In this retrospective cohort study, PCHF patients were identified using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes in Taiwan’s National Health Insurance Research Database. Risk factors and obstetric outcomes were compared in women with and without PCHF. Results From 2,115,873 birth-mothers in Taiwan between 1997 and 2013, we identified 512 with PCHF (incidence: 24.20/105). More women with than without PCHF were older (≥ 35, 18.16% vs. 9.62%), and had more multifetal gestations (7.42% vs. 1.40%), gestational hypertension (HTN) (19.2% vs. 1.31%), and gestational diabetes mellitus (4.10% vs. 0.67%). After the analysis had been adjusted for confounders, the leading comorbidities associated with PCHF were structural heart diseases (adjusted odds ratio [aOR]: 67.21; 95% confidence interval [CI]: 54.29–83.22), pulmonary diseases (aOR: 13.12; 95% CI: 10.28–16.75), chronic HTN (aOR: 11.27; 95% CI: 6.94–18.28), thyroid disease (aOR: 9.53; 95% CI: 5.27–17.23), and gestational HTN (aOR: 5.16; 95% CI: 3.89–6.85). PCHF patients also had a higher rate of cesarean sections (66.41% vs. 34.46%; p < 0.0001). Conclusion Maternal structural heart diseases, pulmonary diseases, thyroid disorders, and preexisting or gestational HTN are associated with a higher risk of developing PCHF. Birth-mothers with PCHF also had a higher risk of caesarean section and adverse outcomes, including maternal death. Our findings should benefit healthcare providers, and government and health insurance policy makers. Electronic supplementary material The online version of this article (10.1186/s12884-017-1486-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Karen Melchiorre
- From the Department of Obstetrics and Gynecology, Santo Spirito Hospital, Pescara, Italy (K.M.); and Department of Cardiology and Cardiothoracic Surgery (R.S.) and Fetal-Maternal Medicine Unit, Department of Obstetrics and Gynecology (B.T.), St. George's University of London, London, UK
| | - Rajan Sharma
- From the Department of Obstetrics and Gynecology, Santo Spirito Hospital, Pescara, Italy (K.M.); and Department of Cardiology and Cardiothoracic Surgery (R.S.) and Fetal-Maternal Medicine Unit, Department of Obstetrics and Gynecology (B.T.), St. George's University of London, London, UK
| | - Basky Thilaganathan
- From the Department of Obstetrics and Gynecology, Santo Spirito Hospital, Pescara, Italy (K.M.); and Department of Cardiology and Cardiothoracic Surgery (R.S.) and Fetal-Maternal Medicine Unit, Department of Obstetrics and Gynecology (B.T.), St. George's University of London, London, UK.
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