Chapters Transcript Video Women & Heart Disease Click here to view presentation deck Back to Symposium There might be some redundancy in both of our talks as you can see cardiology and ob we overlap a lot, um which is wonderful, right? Um I wanted to start with um a 32 year old um Morbid Lee obese, um African American female multipara who presented um to uh to our clinic 10 days after an uncomplicated vaginal delivery and she is very fatigued and um has this persistent cough that she developed right around the time of um delivery. Her past medical history includes nicotine abuse and preeclampsia and she actually already has started to smoke again. Her blood pressure is a little bit low. Her heart rate is elevated. She looks a little bit distressed and she's slightly hypoxic. Um She does get um diagnosed um with um um a respiratory illness um by our urgent care team and get sent home. Um telling um with being told that she needs to rest. Um One week later, she presents again um to um our clinic and um has continued symptoms, cough has gotten worse. She's very dym. Now, um she um is um started on an antibiotic, giving an albuterol inhaler and was told that she is new onset asthma. She um mentions actually in that visit that it's really hard for her to take care of her newborn and um she feels um that she absolutely can't breathe anymore even sitting upright um breastfeeding. Um She was then um this is a true community story um called 911 for severe respiratory distress two days later and was in cardiac arrest and died. Um This was just nine months ago. Um We are trying to reduce maternal mentality just because of this. Um, young females dying because of undiagnosed cardiomyopathies. Um, autopsy showed a severely dilated left ventricle. She had a peripartum cardiomyopathy and um probably died from acute heart failure. I'd have a trickle arrhythmia. So, cardiovascular disease in pregnancy has a lot of faces. It's heart failure, it's pulmonary hypertension. You can have an aortic dissection. You can have possible arrhythmias. Um You can have non var congenital heart disease. You can have um con considerably coronary artery disease, women becoming older and older because we are pursuing our careers first before starting a family, right, advanced age leads to more complications and then you can have your congenital BVE disease as well. Um In the cardiomyopathy range, we can do um split them into two groups. The dilated cardiomyopathy, which have happened very common um out of the pregnancy induced cardiomyopathies and the underlying hypertrophic cardiomyopathy that worsen during pregnancy. So the initial step um that most of these women um present as a respect is with hypertension and you probably have a lot of patients with hypertension prior or during um their pregnancy. We can do pre-existing hypertension, gestational hypertension, which then goes into um the more um difficult picture of preeclampsia. And then you can have a combination of a lot of different um scenarios, um pre-existing hypertension. Um Currently by our obstetrics cardiology, um Task force is considered 100 and 90 100 and 40/90. Although I have to tell you, I would go with our regular definition of 100 and 30/80. Um If a young female has a blood pressure of 100 and 35 it should just raise your eyebrows a little bit and consider her a little bit higher risk. Um So we look at risk assessment for preeclampsia. Um and we look at um hypertensive heart disease during a previous pregnancy, chronic kidney disease, autoimmune disease, such as lupus. Um sarcoidosis would fall into this um or antiphospholipid antibody syndrome type one or type two diabetes, chronic hypertension and I'll just throw in your metabolic syndrome as well. Um The moderate risk for preeclampsia includes more than one or the following risk factors. It's your first pregnancy, you're over the age of 40. Um you have a pregnancy interval of more than 10 years and morbidly obese family history of pre um preeclampsia are multi power. So with that patient comes to you, um she has a couple of risk factors. Um Can I go back back that red button? Good. Perfect. So one or more risk factors. Think about your patient population, blood pressure, 100 and 35 morbidly obese first pregnancy indication for aspirin because we do treat and prevent preeclampsia with that hopefully or lower the risk of preeclampsia. Um Think about your po population again, African American probably Gloria would um include that now too. And with recent studies is a risk factor for preeclampsia. You have a first pregnancy, African American female with maybe a family history of preeclampsia. She ought to be on aspirin. I, um, have a family of preeclampsia. I was um, um, at one point had my first child, I was clearly not on aspirin, right. So, um, I think we can all do better putting these young patients on aspirin, um, between 81 and 100 and 62. Um, it's up to you, I think um, we are tending to do 100 and 62 these days. Um, if we can and bleeding risk is not too high, 81 is fine too, but just starting that little bit of aspirin, uh, preconception or right in the beginning of pregnancy really does reduce mortality and morbidity for preeclampsia. Um Then you have your young female, either preconception or during pregnancy. You have to address their diet. Why is the Medicaid population at such a risk? Because their diet usually is very, very high in salt. I have a Medicaid um patient, I usually do discuss access to food and there are tons of programs uh um programs out there who can help you with access to healthier food. Um Gloria, we have a couple of social workers that help um delivering healthy food um to the families. Um I think we can give you links at the end of this conference. Um There's blood pressure cups also that get delivered to them. But I discuss the unprocessed diet um which is hard to do on a very low budget. No fast food. You have to include the cheeses in there, the cheesy diet, right? Um Nothing canned, nothing dry that you just have to throw in a pot to warm up weight loss really has no data. Um It has data for our regular um population preconception that it really does lower blood pressure during pregnancy. There's clearly no data out there, but we do want a council about a sensible weight gain, try not to eat poorly during your pregnancy. Just the common things takes five minutes. Um identify some of their high salt food diets. I usually ask for salty food, sweet food. Um tell them to quickly give me a rundown through their pantry and see where I can help um with reducing salt in the diet. Um So for moderate hypertension, meaning blood pressure is above 100 and 40/90. Um we should definitely treat that um we have to balance the maternal compilation um complications to the fetal complication. And that's when, you know, with our cardio obstetric programs, we usually have a phone call to see what would be the better choice of blood pressure medication for this particular female um preeclampsia with a sustained blood pressure of a more than 100 and 60 or diastolic blood pressure, more than 100 and 10. Um we usually sent to the hospital. Um Our treatment goal is 100 and 20/80 first line agent labial law. Um we usually start um with a drug. Um I love beta blockers just from the benefit for the heart itself. Right? Antibotic effect has very little um complications for the fetus. Um It can sometimes in very high doses um reduce fetal growth. Um That's again when the collaboration comes in goes like, hey, we have a little bit of problems with our fetus growing. What do you think? Can you change your anti hypertensive medications a little bit? Absolutely. Um You have to be cautious with neonatal tachycardia and hypoglycemia on patients with high dose beta blockers. And it's um all beta blockers are safe. Just don't use a t regular doses, 200 mg twice daily, super safe for you to start. So you see a patient pregnant blood pressure is up 100 and 40/90. Give me a call, give Gloria a call, start them on 200 mg of labetalol twice a day if they're not severely bradycardic, send them all away and you've done a super good deed and don't forget that Aspirin. Um Nifedipine, um I use usually as a second um line. Um you know, calcium channel blockers and cardiology have become a little bit under scrutiny. Um It's still very safe to use for um pregnancy induced hypertension and preeclampsia. Um It can sometimes lead to, you know, ma maternal hypertension, especially if the patient is severely dehydrated from hyperemesis. Um and it can use to um lead to fetal hypoxia when used with your magnesium sulfate. Um verapamil uh change from Nifedipine to Vimal can be sometimes considered if Nifedipine is just not cutting your blood pressure goal in combination with your beta blockers. Um those are usually really tough decision. You can totally leave them to us um phone call or just an urgent consult. We usually get them in within seven days. Um vasodilators absolutely can be used. You sometimes see us, you know, doing labetalol. Nifedipine verapamil is not cutting it. We got to start hydrALAZINE, hydrALAZINE causes reflex tachycardia, right. So you do want to use it with your beta blocker. Um You just don't want to do Nifedipine plus hydrALAZINE, that poor patient's heart rate is going to be 100 and 30 they feel miserable. Um Nitroglycerin can be used as well. Um and nitro prosy in an extreme emergency can absolutely be administered as well. Um they are all safe during lactation as well. Um The only caveat again, you know, just make sure that they are adequately hydrated. Um The most problematic patient I feel like um who I have to treat um is the hyperemesis patient with a blood pressure of 100 and 50 um very hard to treat. They get very orthostatic, they have a lot of side effects. Um and you just have to make sure that you treat the hyperemesis and then try with IV hydration or, or a good oral hydration, um get them a little bit more stabilized. So, angiotensin receptor blockers not safe during pregnancy. I wish we could use them. Um We just can't enalapril and captopril are safe during lactation. Um and they are really good in lowering the blood pressure. But as per my experience and I think Laura, you noticed that too. They are clearly not as effective as our beta blockers and our calcium channel blockers. Um You do um can I usually start them 6 to 9 months, post delivery and slowly amp them up and slowly fade up the calcium channel blockers and the beta blockers. And that usually does the trick. But even transitioning someone a year just last week, a year, postpartum, I transitioned her from the LA and the nedine to an and tens and receptor blocker very slowly. A week later, she calls me my blood pressure again. 100 and 70 Doctor Lynch and I'm like, hm. Ok. Back on the Libet, back on the Nifedipine, we'll try again in six months. These high blood pressures can be very persistent, very persistent. You have to follow them almost on a monthly basis. You have to reiterate to the new mom. They have to keep checking their blood pressure. They have to call for headaches. They cannot forget about this. So many times I get someone skip their two and three month postpartum follow up appointment come in with severe headaches and a blood pressure of 100 and 80. It's so important. It's constant reiteration. My nurses have to call them constantly remind you you have to come, I can't, baby is sick. Well, you have to come, come in with a sick baby, you know, do whatever it takes, come on back into our clinic. Um So dosage is a little bit. Um and if you just want to write this down, labetalol 200 twice a day. Perfect starting dose, right? Um Not a whole lot can happen with this. Get a baseline EKG make sure they don't have a sinus bradycardia of 50. I would even start it if their heart rate is 60. Um Nifedipine, we usually start at 60 to 100 and 20 high dosages. Methyldopa. Don't you wish? Methyldopa was still available? Well, they have stopped producing it. Um um just because um there was just no margin to for profit in there. It was such a wonderful medication, you cannot get it anymore. Thiazide diuretics um should be a second line agent can be used as well. And then remember we don't want all gen tens and receptor blockers. Um So severe hypertension, 100 and 60/100. Um, we recently had a case, you know, a patient comes in like, I think her blood pressure was like 100 and 50. Her diastolic was like 85. She had symptoms. She did not look good. I called Gloria. I was like, uh I am not so sure about this, you know, because the moment she walks out of this office, either her blood pressure is 100 and 40 or her blood pressure is 100 and 60. I felt she didn't look so good. We send her in, right? Don't get hung up on a number. If the blood pressure is up, patient looks crappy. They're going to labor and delivery and they might just be there for 23 days and then come right back to you, right? Um And that's not a sign that they didn't have to be there. Um It's a sign that they are high risk, right? Um IV La Beol in these cases are used. Um we sometimes try oral nifedipine hydrALAZINE again because of the perinatal effects we are using again, 2nd, 3rd line. Um and if they have severe hypertension and they're starting to go into pulmonary edema, we're starting a nitroglycerin drop on them um sodium nitro prosy can be used, but it has cyanide toxicity. I think I've used it once uh during my whole career. Have you ever used it? I've never used it here. Um It is dangerous to use, but sometimes we are backed really up against the wall and um the pulmonary edema we're seeing the blood pressure accelerating delivery has to be somehow held for the next couple of hours. We're starting nitro prosy. Um And again, it's that what I want to convey to you guys, nothing is ever forbidden, right? It's this clinical choice. We're weighing the maternal health and the fetal health. So after we have treated the per per eclampsia, peripartum preeclampsia, we have the peripartum cardiomyopathy, um ejection fraction less than 50%. We usually see a mild dilatation of the left ventricle with a globally reduced function. We never really see wall motion abnormalities um and it usually peaks during your third trimester. It gets worse with that. A brain natural PP. Our BNP markers are off in pregnancy, they are always off. So our first BNP value is of no value at all but trending it and looking at it and looking at baselines versus elevation or decrease really does help us, right? So the er calls me with a peripartum cardiomyopathy and says the B MP is 1200. Well, I don't know what to do with that, but two days later, if the B MP is 1600 I know I'm not going the right way, right? Um We cautiously have to look at trends, basal um dilatory and vasoconstrictor changes during pregnancy from second to third trimester happened every single week. This is a fast moving state, right? So we have to take any trends also with caution and look, hey, she just went from here to here. I think we have to be cautious with that B MP level. Just look at it and think about it, have it in the back of your mind, but don't use it as a regular heart failure parameter. Um Chest X rays absolutely can be done these days. Um With good shielding. Are they really beneficial these days? I mean, if you want to exclude pneumonia? Sure. Right. For heart failure, I think our echocardiogram is perfect. Um So I usually leave that up to um our internist if they think the patient has pneumonia. Absolutely. Get a chest X ray, um anticoagulation. So, anticoagulation, Gloria um did um um talk about this a little bit. Um Thromboembolic risk in pregnancy is high. If you have high blood pressure or peripartum cardiomyopathy, you're at the highest risk for thromboembolic risk. Meaning on top of your aspirin, you should be on low molecular weight, heparin, tough one, right. Um These are young females. Um they have to give themselves injections, they have to um do it on a regular basis. Right? Postpartum. Don't forget they're still at higher risk. So, taking them off postpartum, off their treatment before is not the right thing. Continue them and just pretend it's their fourth trimester. So you continue everything. So many times I see um moms with uh pulmonary embolisms who um have been taken off, abruptly off the aspirin and the low molecular like heparin plus the labial on the Nephetapine, the blood pressure is 100 and 80. They're in heart failure and they have a pulmonary embolism, continue treating it. And I tell them pretend you have a second pregnancy coming once you're over nine months, we'll reassess, right? And sometimes if they're doing really good and the injection infection normalizes their blood pressure normalizes, you know, three months postpartum and they look fabulous clinically. You can slowly fade things off, but the initial phase postpartum leave them on. Um There's a couple of slides for advanced heart failure that I don't think we have to go through just in time. I think we're a little bit over. Um I think there are some um guideline based medicine um treatment that um I have laid out for you there. Um Basically at that point, your primary care is done. They belong to an expert. Um You can double check us, please double check us. So many times you guys have called me and I was like, doesn't that patient shouldn't be in the hospital? Like, shouldn't we start an enter tensive receptor blocker because the patient is breastfeeding? I'm like, yes Thank you. You know, we, this is a team, right? We miss things, you know, with statin therapy, we miss optimizing statins, right? We miss optimizing blood pressure. We miss treating our um postpartum pregnant patients as well. You might see her. She doesn't show up to me because she has to cross a bridge, right? Or um doesn't have transplantation, but she comes because she wants a flu shot right. Here you go. So make sure they're on guideline directed medical therapy. Um If they're nursing, we are restarting in cardiomyopathy, they're intensive receptor blockers and we are continuing their beta blockers. The rest of our guideline American medical therapy is still off. Um And um I think I have the outpatient. No. Um So that's basically it, I'm not gonna go into anything because of time restrictions. Published Created by Related Presenters Petra Lynch, M.D. CardiologySentara Cardiology Specialists View full profile
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