Cardiovascular Disease

Risk Detection and ECG

Interpretation in Pregnancy
Radityo Prakoso
President of Indonesian Heart Association
Division of Pediatric Cardiology and Congenital Heart Disease, Dept of Cardiology and Cardiovascular
Medicine Faculty of Medicine Universitas Indonesia, National Cardiovascular Centre Harapan Kita
 EPIDEMIOLOGY
• Cardiovascular disease is the leading cause of
death and non-obstetric mortality in 0.4-4% of
pregnancies/delivery,
• The average mortality rate of pregnant women
with NYHA FC I and II is 0.4-6.8%; higher in
patients with NYHA FC III-IV
• Cardiovascular disease was the cause of death in
5.6% of 1459 pregnancies in the United States from
1987-1990.

Mehta L, Warnes C, Bradley E, Burton T, Economy K, Mehran R et al. Cardiovascular Considerations in Caring for Pregnant Patients:
A Scientific Statement From the American Heart Association. Circulation. 2020;141(23). 2
 EPIDEMIOLOGY
• In Indonesia, maternal mortality rate due to heart disease in
pregnancy ranges from 1-2%
• Main leading causes :

1. Rheumatic heart disease — >90% with mitral

valve abnormalities (mitral valve stenosis)
2. Congenital heart disease — Atrial septal defect
(ASD) is the second most prevalent type of CHD
3. Cardiomyopathies
•
Panduan Tatalaksana Penyakit Kardiovaskular pada Kehamilan. PERKI. 2021.
3
 EPIDEMIOLOGY
• 3.1% of 20% of patients who were treated at the Obstetrics and
Gynecology Section of the RSCM/FKUI Jakarta and were
consulted to a cardiologist
• Death rate from heart disease is fourth after
eclampsia, bleeding and infection
• Mortality rate 1.21% —> highest found in multipara
1.6%
• Pregnant women with heart disease (excluding
hypertension in pregnancy) were 31 cases per year or
0.65% per year with a mortality rate of 4.88%.

Mehta L, Warnes C, Bradley E, Burton T, Economy K, Mehran R et al. Cardiovascular Considerations in Caring for Pregnant Patients: A Scientific Statement From the American
Heart Association. Circulation. 2020;141(23).
Boestan IN. Penyakit Jantung & Kehamilan. Airlangga University Press; 2007.
4
Physiological Changes
in Cardiovascular
System during
Pregnancy
 Hemodynamic Changes

1. Structural changes of left ventricle (LV)

2. Activation of renin-angiotensin-aldosterone system
(RAAS)
3. Hormonal fluctuation
4. Increase in plasma volume 30-50% from 1st
trimester
5. Increased resting cardiac output up to 40% — > peaks
at 20 weeks of gestation
6. Declined systemic vascular resistance
Mehta L, Warnes C, Bradley E, Burton T, Economy K, Mehran R et al. Cardiovascular Considerations in Caring for
Pregnant Patients: A Scientific Statement From the American Heart Association. Circulation. 2020;141(23).
 Hemodynamic Changes

Mehta L, Warnes C, Bradley E, Burton T, Economy K, Mehran R et al. Cardiovascular Considerations in Caring for
Pregnant Patients: A Scientific Statement From the American Heart Association. Circulation. 2020;141(23).
Various Medical
Condition during
Pregnancy

8
 Valvular Heart Disease in Pregnancy
• Valvular heart disease (VHD),although not as
common as hypertension,heart failure or
coronary disease is an important,and
challenging, clinical entity.
• Some substantial advances have been made in
the understanding the disease including the
aetiology ,pathophysiology and its
characteristics.

Mehta L, Warnes C, Bradley E, Burton T, Economy K, Mehran R et al. Cardiovascular Considerations in Caring for
Pregnant Patients: A Scientific Statement From the American Heart Association. Circulation. 2020;141(23).
 Valvular Heart Disease in Pregnancy
• Valvular heart disease pathologies in women of child- bearing age are most
commonly congenital but may include rheumatic, acquired, and native
degenerative causes.
• Pregnancy in women with mechanical prosthetic heart valves is associated
with increased risk of fetal and maternal morbidity and mortality.
• Maternal risks include increased mortality, valve thrombosis–associated valvular
dysfunction, heart failure, stroke, and maternal hemorrhage.

Women with a history of valvular heart disease should undergo preconception

evaluation by the cardio-obstetrics team.
Mehta L, Warnes C, Bradley E, Burton T, Economy K, Mehran R et al. Cardiovascular Considerations in Caring for
Pregnant Patients: A Scientific Statement From the American Heart Association. Circulation. 2020;141(23).
 Rheumatic Heart Disease
Rheumatic heart disease (RHD) is a life-threatening heart condition which results from
damage to heart valves caused by one or several episodes of rheumatic fever, an autoimmune
inflammatory reaction to infection with streptococcal bacteria (streptococcal pharyngitis or
strep throat)
• ARF recurrences causes progressive valve damage —> mitral and/or aortic valves
• In chronic conditions will leads to complications as follow:
• atrial fibrillation
• congestive heart failure
• strokes
• endocarditis
• death
• Non surgical intervention or cardiac surgery often necessary

Mehta L, Warnes C, Bradley E, Burton T, Economy K, Mehran R et al. Cardiovascular Considerations in Caring for
Pregnant Patients: A Scientific Statement From the American Heart Association. Circulation. 2020;141(23).
 Rheumatic Heart Disease
CLINICAL DIAGNOSIS of RF
Jones criteria

Kumar R, Antunes M, Beaton A, Mirabel M, Nkomo V,

Okello E et al. Contemporary Diagnosis and
Management of Rheumatic Heart Disease: Implications
for Closing the Gap: A Scientific Statement From the
American Heart Association. Circulation. 2020;142(20).
 Rheumatic Heart Disease
Clinical diagnosis of carditis
• Based on the presence of significant murmurs (suggestive of mitral and/or aortic
regurgitation), pericardial rub, or an unexplained cardiomegaly with congestive
heart failure
• Occasionally becomes difficult, especially when carditis is the sole
manifestation carditis occurs on preexisting RHD

Kumar R, Antunes M, Beaton A, Mirabel M, Nkomo V, Okello E et al. Contemporary Diagnosis and Management of Rheumatic Heart Disease: Implications for Closing the Gap: A Scientific
Statement From the American Heart Association. Circulation. 2020;142(20).
 Hypertensive Disorders in
Pregnancy
Hypertensive disorder in pregnancy are classified into 4 categories :
1. Preeclampsia/eclampsia
2. Gestational hypertension
3. Chronic hypertension
4. Chronic hypertension with superimposed preeclampsia

ACOG and AHA highlighted the need for a multidisciplinary management strategy
incorporating lifestyle and behavioral modifications, including diet, exercise,
and smoking cessation, as well as EMR–based standardized algorithms
targeting cardiovascular risk factors.
Mehta L, Warnes C, Bradley E, Burton T, Economy K, Mehran R et al. Cardiovascular Considerations in Caring for
Pregnant Patients: A Scientific Statement From the American Heart Association. Circulation. 2020;141(23).
 Hypercholesterolemia in
Pregnancy
• Total cholesterol, triglycerides (TG), and low-density lipoproteins (LDL) levels rise
steadily during pregnancy and reach peak levels at the time of delivery.
• However, neither TG nor total cholesterol >250 mg/dL in normal pregnancies.27
• After delivery, major lipoprotein levels decline over the next 3 months to near
prepregnancy levels (Data Supplement Figure 3).
• Estimation of atherosclerotic CVD risk and documentation of baseline low-
density lipo- proteins with a lipid panel are recommended for adults who
are ≥20 years of age and not on lipid-lowering therapy.

It is preferable to screen for dyslipidemia before pregnancy according to the National

Lipid Association’s recommendations for patient-centered management of dyslipidemia
Mehta L, Warnes C, Bradley E, Burton T, Economy K, Mehran R et al. Cardiovascular Considerations in Caring for
Pregnant Patients: A Scientific Statement From the American Heart Association. Circulation. 2020;141(23).
 Ischemic Heart Disease in Pregnancy
• The risk of acute myocardial infarction (MI) is 3-4 fold higher in pregnant
women compared nonpregnant women
• The incidence is between 2.8 and 8.1 cases per 100000 deliveries, with
mortality rates of 4.5% to 7.3%.
• Although atherosclerosis accounts for <50% of patients, pregnancy-
related spontaneous coronary artery dissection and MI with
nonobstructive coronary arteries are prevalent causes of acute MI in
pregnancy.
• Mehta L, Warnes C, Bradley E, Burton T, Economy K, Mehran R et al. Cardiovascular Considerations in Caring
for Pregnant Patients: A Scientific Statement From the American Heart Association. Circulation. 2020;141(23).
 Ischemic Heart Disease in Pregnancy
• A multidisciplinary team approach should be adopted, and the treatment strategy is
guided by the clinical presentation.
• In patients with atherosclerotic STEMI, timely coronary reperfusion by
percutaneous coronary intervention (PCI) is recommended.
• Fetal radiation protection with lead shielding and radiation reduction measures
should be implemented.
• If PCI is not readily available —> thrombolysis is very rarely used the risk of
maternal hemorrhage.
• An invasive approach is also recommended in patients with NSTEMI who are
unstable or have high atherosclerotic burden.
• Stable patients at low risk can be managed conservatively.
Mehta L, Warnes C, Bradley E, Burton T, Economy K, Mehran R et al. Cardiovascular Considerations in Caring for
Pregnant Patients: A Scientific Statement From the American Heart Association. Circulation. 2020;141(23).
 Cardiomyopathies in Pregnancy
• Both dilated cardiomyopathy and peripartum cardiomyopathy (PPCM) may
represent a condition within a spectrum of similar pathophysiology
• PPCM —> new-onset cardiomyopathy with systolic dysfunction (LVEF<45%)
without a reversible cause presenting near the end of pregnancy or in the postpartum
period in a woman without known heart disease and is a significant cause of maternal
morbidity and mortality.
• The prognosis for women with PPCM is strongly linked to LV ejection fraction at
presentation
• Appropriate contraception choices and risk in future pregnancies of recurrent
PPCM must be dis- cussed early in the management of these women.

Mehta L, Warnes C, Bradley E, Burton T, Economy K, Mehran R et al. Cardiovascular Considerations in Caring for
Pregnant Patients: A Scientific Statement From the American Heart Association. Circulation. 2020;141(23).
 Arrhythmias in Pregnancy
• Sustained arrhythmias are more frequent in patients with underlying structural
heart disease or thyroid/electrolyte disturbances.
• Stable SVT treatment should be no different in pregnant patients —> if vagal
maneuvers fail, then intravenous adenosine may be used.
• Catheter ablation for atrial arrhythmias may be needed if medical therapy fails,
ideally with minimal radiation exposure.
• New-onset atrial fibrillation in pregnancy usually indicates underlying heart
disease and should be treated on an inpatient basis by a cardiologist. If the patient
is unstable, direct cardioversion is recommended over chemical cardioversion
because it is highly safe and effective.
More complex arrhythmias require a cardio-obstetrics team approach, and management
strategies may include initiation or titration of antiarrhythmic therapy or consideration of
an electrophysiological study and radiofrequency ablation.
Mehta L, Warnes C, Bradley E, Burton T, Economy K, Mehran R et al. Cardiovascular Considerations in Caring for
Pregnant Patients: A Scientific Statement From the American Heart Association. Circulation. 2020;141(23).
 Aortic Disease and Pregnancy
• Aortopathy in the pregnant woman carries substantial cardiovascular risk because of the
combination of hemodynamic changes and hormonally driven structural
effects on the integrity of vascular/connective tissue.
• The heritability and syndromic features of genetic aortopathies are heterogeneous, as
is the risk of pregnancy-associated maternal cardiovascular morbidity and mortality.

The cardio-obstetrics team approach would also include consideration of intervention if

appropriate, multidisciplinary delivery planning, and postpartum follow-up, including when
surgical replacement of the aorta is recommended
Mehta L, Warnes C, Bradley E, Burton T, Economy K, Mehran R et al. Cardiovascular Considerations in Caring for
Pregnant Patients: A Scientific Statement From the American Heart Association. Circulation. 2020;141(23).
 Venous Thromboembolism (VTE)
• VTE includes deep venous thrombosis (DVT) and pulmonary embolism (PE)
• VTE is 4-5 times more common during pregnancy.
• Absolute risk of VTE during pregnancy remains low at 0.3% for PE and 1.2% for DVT,
with the majority (70%) occurring in the postpartum period.

• DEEP VEIN THROMBOSIS

• DVT in pregnancy is often proximal (iliac or iliofemoral) and predominantly left-
sided —> if USG examination is negative and clinical suspicion remains high,
serial USG measurements in 3 to 7 days or MRI of the pelvis should be considered.

Mehta L, Warnes C, Bradley E, Burton T, Economy K, Mehran R et al. Cardiovascular Considerations in Caring for
Pregnant Patients: A Scientific Statement From the American Heart Association. Circulation. 2020;141(23).
 Venous Thromboembolism (VTE)
• PULMONARY EMBOLISM
• The diagnosis of PE is challenging because the presentation often overlaps with
symptoms common during normal pregnancy
• It therefore requires a high index of suspicion, particularly in the presence of risk
factors such as a history of VTE or thrombophilia.
• The initial evaluation for PE should include ECG, chest x-ray, and blood tests to
rule out alternative causes such as ischemia, anemia, or infection.

Mehta L, Warnes C, Bradley E, Burton T, Economy K, Mehran R et al. Cardiovascular Considerations in Caring for
Pregnant Patients: A Scientific Statement From the American Heart Association. Circulation. 2020;141(23).
Pulmonary

Embolism
Mehta L, Warnes C, Bradley E, Burton T,
Economy K, Mehran R et al. Cardiovascular
Considerations in Caring for Pregnant Patients:
A Scientific Statement From the American
Heart Association. Circulation.
2020;141(23).
 Congenital Heart Disease in Pregnancy
• Based on ROPAC (2007-2018) —> among 5739 pregnancies in 53 countries
CHD was the most prevalent form of structural heart disease (57 %)
• United Kingdom and Ireland Confidential Enquiries into maternal deaths reported that of
910 maternal deaths between 2009 and 2014, 22.5 percent were caused by heart
disease, and a minority from congenital heart disease
• Maternal cardiac and neonatal complication rates are considerable in pregnant women
with congenital heart disease.
• Patients with impaired subpulmonary ventricular systolic function and/or severe
pulmonary regurgitation are at increased risk for adverse cardiac outcomes.

1. Roos-Hesselink J, Baris L, Johnson M, et al. Pregnancy outcomes in women with cardiovascular disease: evolving trends over 10 years in the ESC Registry Of Pregnancy And Cardiac disease (ROPAC). Eur
Heart J 2019; 40:3848.
2. https://www.npeu.ox.ac.uk/mbrrace-uk/reports/confidential-enquiry-into-maternal-deaths.
3. Khairy P, Ouyang D, Fernandes S, Lee-Parritz A, Economy K, Landzberg M. Pregnancy Outcomes in Women With Congenital Heart Disease. Circulation. 2006;113(4):517-524.
Congenital Heart Disease in Pregnancy

Xie D, Fang J, Liu Z, Wang H, Yang T, Sun Z et al. Epidemiology and major subtypes of congenital heart defects in Hunan Province, China. Medicine. 2018;97(31):e11770.
 Diagnosis of
Cardiovascular
Disease
during
Pregnancy
 Electrocardiography
1.The electrocardiogram of most pregnant women has a left
heart axis deviation of 15-20 degree.
2.The ST/T wave changes are transient, with inverted Q and T
waves in lead III, and T inversion in V1-V2 or up to V3.
3.The changes may mimic left ventricular hypertrophy or
other structural heart disease.
4.Holter monitoring should be performed in patients with a
known history of paroxysmal or persistent arrhythmias
(ventricular tachycardia, atrial fibrillation/flutter) or who
complain of palpitations.
Panduan Tatalaksana Penyakit Kardiovaskular pada Kehamilan. PERKI. 2021.
 Echocardiography
1.Transthoracic echocardiography (TTE) examination is the
examination method that is often chosen for pregnant women,
because it can be repeated, widely available, relatively
inexpensive, and can be used both in the clinic and in many
other rooms in the hospital.
2.Transesophageal echocardiography (TEE) is relatively safe,
however, the risk of vomiting/aspiration and a sudden
increase in intra-abdominal pressure may occur, and fetal
condition monitoring is necessary.

Panduan Tatalaksana Penyakit Kardiovaskular pada Kehamilan. PERKI. 2021.

ECG and Echocardiography in
Pregnancy

Panduan Tatalaksana Penyakit Kardiovaskular pada Kehamilan. PERKI. 2021.

 Exercise Testing
1. There is no evidence that exercise testing increases the risk of miscarriage.
2. It is recommended to perform a submaximal exercise test (80% predicted
maximal heart rate) in asymptomatic pregnant women with suspected
cardiovascular disease.
3. Maximum heart rate and maximal oxygen uptake are known to predict
maternal cardiac events during pregnancy.
4. Exercise capacity that can reach >80% is associated with a safe
pregnancy.
5. Stress echocardiography using a bicycle ergometer will increase diagnostic
specificity.
6. Dobutamine stress testing is rarely indicated

Panduan Tatalaksana Penyakit Kardiovaskular pada Kehamilan. PERKI. 2021.

 Diagnostics with ionizing radiation
1. The highest risk of exposure to ionizing radiation occurs during the formation
of fetal organs (organogenesis) and the early period of fetal development
— > decrease in the 2nd trimester, and gets lower in the third trimester.
2. Ionizing radiation procedures should be postponed until >12 weeks after
the last menstrual period.
3. If ionizing radiation is necessary, the risks and benefits must be communicated
to the patient, and an informed consent form must be signed.
4. Chest radiography is only done when other methods fail to find the cause of a
symptom.
5. CT is not recommended, except for the diagnosis of PE or aortic
abnormalities (low radiation of 0.01-0.66 mGy can still be used)
Panduan Tatalaksana Penyakit Kardiovaskular pada Kehamilan. PERKI. 2021.
 Magnetic Resonance Imaging
1.Magnetic resonance imaging (MRI) examination in pregnant
women is recommended only when other diagnostic tools
are not sufficient to establish a definitive diagnosis.
2.MRI examination is preferred over ionizing radiation-based
diagnostic tools.
3.Gadolinium-based contrast in pregnancy is controversial,
particularly in the first trimester.

Panduan Tatalaksana Penyakit Kardiovaskular pada Kehamilan. PERKI. 2021.

 Heart Catheterization
1. Cardiac catheterization is rarely performed in pregnant women for
diagnostic purposes, but can be used to guide an interventional
procedure.
2. The average radiation exposure to cardiac catheterization of the
unprotected abdomen is 1.5 mGy and <20% of the radiation exposure
can reach the fetus.
3. Electrophysiological studies should be performed only in arrhythmias
refractory to medical therapy and causing hemodynamic
compromise.
4. The electroanatomical mapping system should reduce the radiation
dose.

Panduan Tatalaksana Penyakit Kardiovaskular pada Kehamilan. PERKI. 2021.

 HOWEVER…
Nowadays we can use zero fluoroscopy
technique to perform catheter intervention to
treat pregnant patients with structural heart
disease, especially with those with congenital
heart disease.

34
Procedures should follow the “as low as reasonably” principle
● Use echo-guidance when possible
● Place the source as distant as possible
from the patient and the receiver as close
as possible to the patient
● Use only low-dose fluoroscopy
● Favour anteroposterior projections
● Avoid direct radiation of the abdominal
region
● Collimate as tightly as possible to the area
of interest
● Minimize fluoroscopy time
Zero fluoroscopy
● Utilize an experienced cardiologist
2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy. European
Heart Journal, 39(34), pp.3165-3241.
 Radiation Exposure in Septal Defect and Ductus
Arteriosus Closure with Fluoroscopy Guiding in
NCCHK
Evenpy though the dose of
could be minimal, it is
fluor o s DAP

b e t t e r to avoid
Flu
ti oro
me ( m in)

c othe radiation
sure s c o mpletely 9. 36 u Gy m2
Atrial Septal Defec t
Ventricular
sc op y 4.0 e 35 uGym2
Septal Defect
Patent
8
4.2
pregnancy
during 37.60 uGy.m2
Ductus

xp o Arteriosus
0. 7
Data updated per May 2021

Mahesh, M., 2001. Fluoroscopy: Patient Radiation Exposure Issues. RadioGraphics, 21(4),
pp.1033-1045.
Our Initial
Zero
Fluoroscopy
Experience
in NCCHK
Our Experience of Zero Fluoroscopy ASD closure in
NCCHK
No Age (year) Diagnosis Device Procedural time

ASD secundum 18-22 mm,

1 25 PH, G1P0A0 pregnant 24 ASO no 28 mm 64 mins
weeks

2 30 ASD secundum 8-13 mm, ASO no 18 mm 49 mins

G2P1A0 pregnant 17 weeks

3 23 ASD secundum 30 mm, ASO no 34 mm 27 mins

G1P0A0 pregnant 18 weeks
Just like taking off with a new aircraft for the first
time

Scary?
Maybe
But
why
walk
 Therapy and follow-up of pregnant women with
cardiovascular disease requires continuous
collaboratio
from obstetrics and gynecology specialists
Mehta L, Warnes C, Bradley E, Burton T, Economy K, Mehran R et al. Cardiovascular Considerations in Caring for
Pregnant Patients: A Scientific Statement From the American Heart Association. Circulation. 2020;141(23).
 Pregnant women have various hemodynamic
changes that are physiological in nature.

Diagnosis of cardiovascular disease in pregnant

women is important both before conception and
during pregnancy, considering that pregnant
Take Home women have a risk of contracting various
cardiovascular diseases.
Message Management of cardiovascular disease in
pregnant women must involve obstetric and
gynecological specialists as well as cardiologists
and be carried out comprehensively.

Diagnostic and therapy approach in pregnant

women with cardiovascular disease must consider
the risk to the fetus.
 Thank you!
-We can’t have healthy societies without healthy
mother-