Acquired heart disease – a challenge for the future ?

Dr Dawn AdamsonConsultant Interventional Cardiologist with sub-specialist interest in obstetric cardiology

University Hospital of Coventry & Warwickshire

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Leading causes of maternal deaths 2006-08, UK

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CEMACE 2011

How does this compare to previous years ?

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19541957

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19661969

19721975

19781981

19841987

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19961999

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2008

Acquired

Congenital

Cardiac causes (per million maternities)

maternal mortality 1952-2008

Ao dissection

13%

MI / IHD

21%

SADS

19%

CM

24%Congen

6%

Other

17%

Cause of Cardiac Mortality

C Nelson-Piercy

Leading Causes of Maternal Death2006-2008 (2011 report)

What is happening outside of pregnancy?

Worldwide, 8.6 million women die from heart disease each year, accounting for 1/3 of all deaths in women.

What is happening outside of pregnancy?

Under age 50, women’s heart attacks are twice as likely to be fatal compared to men’s.

In US, 267,000 women die from MI which kills 6x as many women as breast cancer

Since 1984, more women than men have died each year from heart disease and the gap between survival in each continues to widen.

Why are women at risk?

71% of women experience early warning signs of MI with sudden onset weakness that can feel like flu, often with no pain at all.

Medical professionals do not respond to women’s milder symptoms therefore problems often go undiagnosed until late in the disease process.

Smoking, diabetes and abnormal blood lipids erase a woman’s oestrogen protection

Marital stress worsens the prognosis in women with heart disease

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8% 19%

What is it about the pregnant woman that makes her so at risk?

What is it about the pregnant women that makes her so at risk?

Epidemiology– Women are older

and unfitter

Physiological – Cardiac stress

– Increased cholesterol

Pathological– Increased incidence

of diabetes, obesity and smoking

So how are we going to reduce cardiac mortality in pregnancy ?

Reduce the incidence

– Population health

– Pre-pregnancy counselling

Manage it better !

Data from Royal Brompton Hospital / Chelsea & Westminster

Pre pregnancy counselling

Congenital Heart Disease mortality

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10

20

30

40

50

60

19541957

19601963

19661969

19721975

19781981

19841987

19901993

19961999

20022005

2008

Acquired

Congenital

Cardiac causes (per million maternities)

maternal mortality 1952-2008

Why is this ?

Congenital heart disease services recognise the risk to the women of being pregnant and counsel from an early age.

Those at greatest risk are advised against pregnancy and receive appropriate contraception

They are managed by a highly experienced multidisciplinary team

Problems with this model

30-50% of pregnancies are unplanned

Cardiologists need to be giving the advice

– Unprepared

– Lack of knowledge

Risk to individual

Contraception

Large number of women who die in confidential enquiry were not known to cardiac services prior to presentation.

CEMACH (2007) recommendations :

1. “Pre-pregnancy counselling should be provided for women of child-bearing age with pre-existing serious medical condition” which may be aggravated by pregnancy.

2. Women at higher risk of developing cardiac disease in pregnancy

• Obese• Smokers• Existing HT and / or diabetes• FH heart disease• > 35 years old

3. These recommendations especially apply to women prior to undergoing fertility treatments.

So how are we going to reduce cardiac mortality in pregnancy ?

Reduce the incidence

– Pre-pregnancy counselling

– Population health

Manage it better !

Antenatal care challenges

Recognising the high risk woman

Presentation of cardiac conditions mimic normal pregnancy

– SOB, “CP” assumed indigestion, SOA

Recognising the high risk woman

Knowing who to refer

– “Please see this lady whom is very anxious….. She has no cardiac condition and her only FH is that her mother died three hours post her delivery from aortic dissection”

Knowing to refer as early as possible

Referred at 28+2 weeks

The assumption of cure

Tetralogy of Fallots – “repaired as a child”

Assumption – cured Reality – severe PR into volume loaded dilated RV

Mild PS under FU as child, no longer seen by cardiology

Assumption – only mild no concern Reality – DNAd adult cardiology clinic

– Presented at 26 weeks SOB ++ , O/E Thrill and loud murmur

– Mild to moderate PS, Severe PR

Role of the obstetric anaesthetist

Understanding the physiology

Effects of pain

Impact of uterine contraction-induced autotransfusion

Post-partum changes induced by relief of vena caval obstruction

Potential for PPH

Safe use of uterine oxytocic agents

Be aware these women may be presenting to you previously undiagnosed !

Have protocols in place to deal with common cardiac conditions that can cause morbidity and mortality

– Has your department had enough training and experience?

Understanding the impact of cardiac lesions

IHD – Are you familiar with DAPT and do you have a plan to manage it?

Valvular heart disease

– Regurgitant lesions – well tolerated

– Monitor for signs of heart failure

– Treat with diuretics and vasodilators

Stenotic valve lesions

Understanding the echo report !– Gradient across valve = 4V2

Increase velocity – increase gradient !

– AS Avoid tachycardia and bradycardia

Maintain adequate preload in order that the LV may generate an adequate CO across the stenotic valve

Maintain haemodynamic parameters across a narrow therapeutic window

Tachycardia of MS

Who’s managing the patient post delivery ?!

The Multidisciplinary team

MARK

The multidisciplinary Team

Dedicated cardiologist with knowledge, experience or the common sense to “phone a friend” !

Dedicated (experienced) obstetrician whom is not afraid to make decisions

Link cardiac anaesthetist

Challenges to the MDT approach

How do we put this team in place?

Do we have anaesthetists / cardiologists/ obstetricians or physicians whom are trained to deal with such patients?

If not, how do we “encourage” them to seek help?

Who will pay for the women to go and see the obstetric cardiologist?

Does the woman want to travel?

Summary

Cardiac disease is Britain's leading cause of maternal mortality and is here to stay

Our challenge is to identify ways in which we can reduce this

Education of those health professionals dealing with such women needs to be addressed and increased

We need to work in an extended multidisciplinary approach

We need more data on individual conditions in order to both advise women better plus learn how to treat them better

Things will improve !

Heart Disease in Pregnancy

• Includes chapters dedicated to each

condition affecting pregnant women,

including acquired and congenital heart

disease, and associated medical

conditions

• Includes a highlighted section on cardiac

emergencies in pregnancy for quick

reference

Dawn Adamson, University Hospitals of Coventry and Warwickshire, UK,

Mandish Dhanjal, Queen Charlotte's Hospital, Imperial College NHS

Trust, London, UK , and Catherine Nelson-Piercy, St Thomas' Hospital,

Guys & St Thomas' Hospital Trust, UK

Any questions ?

Dawn.adamson@uhcw.nhs.uk