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Comorbidities and Co-Existing Conditions in Heart Failure Around Pregnancy

  • Denise Hilfiker-KleinerEmail author
  • Johann Bauersachs
  • Karen Sliwa
Chapter
Part of the Cardiovascular Medicine book series (CVM)

Abstract

It is estimated that 0.2 to 4% of all pregnancies in industrialized countries are complicated by cardiovascular diseases (CVD) with increasing number of women who develop cardiac problems during pregnancy [1]. Indeed, pregnancy challenges the cardiovascular system and may lead to disease states such as hypertensive complications with its severe forms preeclampsia and the HELLP syndrome (H: hemolysis, EL: elevated liver enzymes, LP: low platelets counts) [2]. Especially the phase towards the end of pregnancy, during delivery and postpartum is a special challenge for the cardiovascular system since it has to cope with massive hormonal fluctuations, fluid changes and mechanical stress. Alterations in metabolism (subclinical insulin resistance in pregnancy) and immune response (repressed in pregnancy and activated after delivery) take place as well. Moreover, endothelial stress promotes hypertensive disorders and additional enhanced coagulation activity lead to higher risk for myocardial infarction and stroke and cardiomyopathies as outlined below. It is therefore not surprising that acceleration of heart failure towards the end of the second trimester, under delivery or in the early postpartum phase is frequently observed in women with pre-existing cardiomyopathies or pulmonary hypertension and is associated with adverse maternal and perinatal outcome [3]. Moreover, the cardiac stress model “pregnancy” may even unmask unrecognized genetic and non-genetic heart diseases [2, 4, 5].

Keywords

Peripartum cardiomyopathy Heart failure Pregnancy 

References

  1. 1.
    Regitz-Zagrosek V, Blomstrom Lundqvist C, Borghi C, Cifkova R, Ferreira R, Foidart JM, Gibbs JS, Gohlke-Baerwolf C, Gorenek B, Iung B, Kirby M, Maas AH, Morais J, Nihoyannopoulos P, Pieper PG, Presbitero P, Roos-Hesselink JW, Schaufelberger M, Seeland U, Torracca L, Bax J, Auricchio A, Baumgartner H, Ceconi C, Dean V, Deaton C, Fagard R, Funck-Brentano C, Hasdai D, Hoes A, Knuuti J, Kolh P, McDonagh T, Moulin C, Poldermans D, Popescu BA, Reiner Z, Sechtem U, Sirnes PA, Torbicki A, Vahanian A, Windecker S, Aguiar C, Al-Attar N, Garcia AA, Antoniou A, Coman I, Elkayam U, Gomez-Sanchez MA, Gotcheva N, Hilfiker-Kleiner D, Kiss RG, Kitsiou A, Konings KT, Lip GY, Manolis A, Mebaaza A, Mintale I, Morice MC, Mulder BJ, Pasquet A, Price S, Priori SG, Salvador MJ, Shotan A, Silversides CK, Skouby SO, Stein JI, Tornos P, Vejlstrup N, Walker F, Warnes C. ESC Guidelines on the management of cardiovascular diseases during pregnancy: the Task Force on the Management of Cardiovascular Diseases during Pregnancy of the European Society of Cardiology (ESC). Eur Heart J. 2011;32(24):3147–97.PubMedGoogle Scholar
  2. 2.
    Hilfiker-Kleiner D, Haghikia A, Nonhoff J, Bauersachs J. Peripartum cardiomyopathy: current management and future perspectives. Eur Heart J. 2015;36(18):1090–7.PubMedPubMedCentralGoogle Scholar
  3. 3.
    Ruys TP, Roos-Hesselink JW, Hall R, Subirana-Domenech MT, Grando-Ting J, Estensen M, Crepaz R, Fesslova V, Gurvitz M, De Backer J, Johnson MR, Pieper PG. Heart failure in pregnant women with cardiac disease: data from the ROPAC. Heart. 2014;100(3):231–8.PubMedGoogle Scholar
  4. 4.
    Hilfiker-Kleiner D, Sliwa K. Pathophysiology and epidemiology of peripartum cardiomyopathy. Nat Rev Cardiol. 2014;11(6):364–70.PubMedGoogle Scholar
  5. 5.
    Ware JS, Li J, Mazaika E, Yasso CM, De-Souza T, Cappola TP, Tsai EJ, Hilfiker-Kleiner D, Kamiya CA, Mazzarotto F, Cook SA, Halder I, Prasad SK, Pisarcik J, Hanley-Yanez K, Alharethi R, Damp J, Hsich E, Elkayam U, Sheppard R, Kealey A, Alexis J, Ramani G, Safirstein J, Boehmer J, Pauly DF, Wittstein IS, Thohan V, Zucker MJ, Liu P, Gorcsan J 3rd, DM MN, Seidman CE, Seidman JG, Arany Z, Imac, Investigators I. Shared Genetic Predisposition in Peripartum and Dilated Cardiomyopathies. N Engl J Med. 2016;374(3):233–41.PubMedPubMedCentralGoogle Scholar
  6. 6.
    Hilfiker-Kleiner D, Bauersachs J. Pregnancy associated cardiomyopathies. Cardiovasc Med. 2014;17(9):245–51.Google Scholar
  7. 7.
    Chung E, Leinwand LA. Pregnancy as a cardiac stress model. Cardiovasc Res. 2014;101(4):561–70.PubMedPubMedCentralGoogle Scholar
  8. 8.
    Conrad KP, Davison JM. The renal circulation in normal pregnancy and preeclampsia: is there a place for relaxin? Am J Physiol Renal Physiol. 2014;306(10):F1121–35.PubMedPubMedCentralGoogle Scholar
  9. 9.
    Liu LX, Arany Z. Maternal cardiac metabolism in pregnancy. Cardiovasc Res. 2014;101(4):545–53.PubMedPubMedCentralGoogle Scholar
  10. 10.
    Roos-Hesselink JW, Ruys TP, Stein JI, Thilen U, Webb GD, Niwa K, Kaemmerer H, Baumgartner H, Budts W, Maggioni AP, Tavazzi L, Taha N, Johnson MR, Hall R, Investigators R. Outcome of pregnancy in patients with structural or ischaemic heart disease: results of a registry of the European Society of Cardiology. Eur Heart J. 2013;34(9):657–65.PubMedGoogle Scholar
  11. 11.
    Ruys TP, Maggioni A, Johnson MR, Sliwa K, Tavazzi L, Schwerzmann M, Nihoyannopoulos P, Kozelj M, Marelli A, Elkayam U, Hall R, Roos-Hesselink JW. Cardiac medication during pregnancy, data from the ROPAC. Int J Cardiol. 2014;177(1):124–8.PubMedGoogle Scholar
  12. 12.
    Ruys TP, Roos-Hesselink JW, Pijuan-Domenech A, Vasario E, Gaisin IR, Iung B, Freeman LJ, Gordon EP, Pieper PG, Hall R, Boersma E, Johnson MR, Investigators R. Is a planned caesarean section in women with cardiac disease beneficial? Heart. 2015;101(7):530–6.PubMedGoogle Scholar
  13. 13.
    van Hagen IM, Roos-Hesselink JW, Ruys TP, Merz WM, Goland S, Gabriel H, Lelonek M, Trojnarska O, Al Mahmeed WA, Balint HO, Ashour Z, Baumgartner H, Boersma E, Johnson MR, Hall R, Investigators R, The ERPT. Pregnancy in women with a mechanical heart valve: data of the European Society of Cardiology Registry of Pregnancy and Cardiac Disease (ROPAC). Circulation. 2015;132(2):132–42.PubMedGoogle Scholar
  14. 14.
    Sliwa K, Boehm M. Incidence and prevalence of pregnancy associated heart disease. Cardiovasc Res. 2014.Google Scholar
  15. 15.
    Van Tintelen JP, Pieper PG, Van Spaendonck-Zwarts KY, Van Den Berg MP. Pregnancy, cardiomyopathies, and genetics. Cardiovasc Res. 2014;101(4):571–8.PubMedGoogle Scholar
  16. 16.
    Sliwa K, Libhaber E, Elliott C, Momberg Z, Osman A, Zuhlke L, Lachmann T, Nicholson L, Thienemann F, Roos-Hesselink J, Anthony J. Spectrum of cardiac disease in maternity in a low-resource cohort in South Africa. Heart. 2014;100(24):1967–74.PubMedPubMedCentralGoogle Scholar
  17. 17.
    Grewal J, Siu SC, Ross HJ, Mason J, Balint OH, Sermer M, Colman JM, Silversides CK. Pregnancy outcomes in women with dilated cardiomyopathy. J Am Coll Cardiol. 2009;55(1):45–52.PubMedGoogle Scholar
  18. 18.
    Gati S, Papadakis M, Papamichael ND, Zaidi A, Sheikh N, Reed M, Sharma R, Thilaganathan B, Sharma S. Reversible de novo left ventricular trabeculations in pregnant women: implications for the diagnosis of left ventricular noncompaction in low-risk populations. Circulation. 2014;130(6):475–83.PubMedGoogle Scholar
  19. 19.
    Krul SP, van der Smagt JJ, van den Berg MP, Sollie KM, Pieper PG, van Spaendonck-Zwarts KY. Systematic review of pregnancy in women with inherited cardiomyopathies. Eur J Heart Fail. 2011;13(6):584–94.PubMedGoogle Scholar
  20. 20.
    Schinkel AF. Pregnancy in women with hypertrophic cardiomyopathy. Cardiol Rev. 2014;22(5):217–22.PubMedGoogle Scholar
  21. 21.
    Ashikhmina E, Farber MK, Mizuguchi KA. Parturients with hypertrophic cardiomyopathy: case series and review of pregnancy outcomes and anesthetic management of labor and delivery. Int J Obstet Anesth. 2015;24(4):344–55.PubMedGoogle Scholar
  22. 22.
    Bello N, Rendon IS, Arany Z. The relationship between pre-eclampsia and peripartum cardiomyopathy: a systematic review and meta-analysis. J Am Coll Cardiol. 2013;62(18):1715–23.PubMedPubMedCentralGoogle Scholar
  23. 23.
    Rana S, Powe CE, Salahuddin S, Verlohren S, Perschel FH, Levine RJ, Lim KH, Wenger JB, Thadhani R, Karumanchi SA. Angiogenic factors and the risk of adverse outcomes in women with suspected preeclampsia. Circulation. 2012;125(7):911–9.PubMedPubMedCentralGoogle Scholar
  24. 24.
    Ahmed R, Dunford J, Mehran R, Robson S, Kunadian V. Pre-eclampsia and future cardiovascular risk among women: a review. J Am Coll Cardiol. 2014;63(18):1815–22.PubMedGoogle Scholar
  25. 25.
    Goel A, Maski MR, Bajracharya S, Wenger JB, Zhang D, Salahuddin S, Shahul SS, Thadhani R, Seely EW, Karumanchi SA, Rana S. Epidemiology and mechanisms of de novo and persistent hypertension in the postpartum period. Circulation. 2015;132(18):1726–33.PubMedPubMedCentralGoogle Scholar
  26. 26.
    August P, Malha L. Postpartum hypertension: “It ain’t over ‘til it’s over”. Circulation. 2015;132(18):1690–2.PubMedGoogle Scholar
  27. 27.
    Haghikia A, Podewski E, Libhaber E, Labidi S, Fischer D, Roentgen P, Tsikas D, Jordan J, Lichtinghagen R, von Kaisenberg CS, Struman I, Bovy N, Sliwa K, Bauersachs J, Hilfiker-Kleiner D. Phenotyping and outcome on contemporary management in a German cohort of patients with peripartum cardiomyopathy. Basic Res Cardiol. 2013;108(4):366.PubMedPubMedCentralGoogle Scholar
  28. 28.
    Patten IS, Rana S, Shahul S, Rowe GC, Jang C, Liu L, Hacker MR, Rhee JS, Mitchell J, Mahmood F, Hess P, Farrell C, Koulisis N, Khankin EV, Burke SD, Tudorache I, Bauersachs J, del Monte F, Hilfiker-Kleiner D, Karumanchi SA, Arany Z. Cardiac angiogenic imbalance leads to peripartum cardiomyopathy. Nature. 2012;485(7398):333–8.PubMedPubMedCentralGoogle Scholar
  29. 29.
    Mannisto T, Mendola P, Vaarasmaki M, Jarvelin MR, Hartikainen AL, Pouta A, Suvanto E. Elevated blood pressure in pregnancy and subsequent chronic disease risk. Circulation. 2013;127(6):681–90.PubMedPubMedCentralGoogle Scholar
  30. 30.
    Vikse BE. Pre-eclampsia and the risk of kidney disease. Lancet. 2013;382(9887):104–6.PubMedGoogle Scholar
  31. 31.
    Williams D. Long-term complications of preeclampsia. Semin Nephrol. 2011;31(1):111–22.PubMedGoogle Scholar
  32. 32.
    Morales A, Painter T, Li R, Siegfried JD, Li D, Norton N, Hershberger RE. Rare variant mutations in pregnancy-associated or peripartum cardiomyopathy. Circulation. 2010;121(20):2176–82.PubMedPubMedCentralGoogle Scholar
  33. 33.
    van Spaendonck-Zwarts KY, van Tintelen JP, van Veldhuisen DJ, van der Werf R, Jongbloed JD, Paulus WJ, Dooijes D, van den Berg MP. Peripartum cardiomyopathy as a part of familial dilated cardiomyopathy. Circulation. 2010;121(20):2169–75.PubMedGoogle Scholar
  34. 34.
    Sliwa K, Fett J, Elkayam U. Peripartum cardiomyopathy. Lancet. 2006;368(9536):687–93.PubMedGoogle Scholar
  35. 35.
    Sliwa K, Hilfiker-Kleiner D, Petrie MC, Mebazaa A, Pieske B, Buchmann E, Regitz-Zagrosek V, Schaufelberger M, Tavazzi L, van Veldhuisen DJ, Watkins H, Shah AJ, Seferovic PM, Elkayam U, Pankuweit S, Papp Z, Mouquet F, JJ MM. Current state of knowledge on aetiology, diagnosis, management, and therapy of peripartum cardiomyopathy: a position statement from the Heart Failure Association of the European Society of Cardiology Working Group on peripartum cardiomyopathy. Eur J Heart Fail. 2010;12(8):767–78.PubMedGoogle Scholar
  36. 36.
    Mielniczuk LM, Williams K, Davis DR, Tang AS, Lemery R, Green MS, Gollob MH, Haddad H, Birnie DH. Frequency of peripartum cardiomyopathy. Am J Cardiol. 2006;97(12):1765–8.PubMedGoogle Scholar
  37. 37.
    Hilfiker-Kleiner D. Social freezing’ of women’s eggs. Eur Heart J. 2015;36(13):773.PubMedGoogle Scholar
  38. 38.
    Sliwa K, Hilfiker-Kleiner D, Mebazaa A, Petrie MC, Maggioni AP, Regitz-Zagrosek V, Schaufelberger M, Tavazzi L, van Veldhuisen DJ, Roos-Hesslink JW, Shah AJ, Seferovic PM, Elkayam U, van Spaendonck-Zwarts K, Bachelier-Walenta K, Mouquet F, Kraigher-Krainer E, Hall R, Ponikowski P, JJ MM, Pieske B. EURObservational Research Programme: a worldwide registry on peripartum cardiomyopathy (PPCM) in conjunction with the Heart Failure Association of the European Society of Cardiology Working Group on PPCM. Eur J Heart Fail. 2014;16(5):583–91.PubMedGoogle Scholar
  39. 39.
    Elkayam U. Clinical characteristics of peripartum cardiomyopathy in the United States: diagnosis, prognosis, and management. J Am Coll Cardiol. 2011;58(7):659–70.PubMedGoogle Scholar
  40. 40.
    Safirstein JG, Ro AS, Grandhi S, Wang L, Fett JD, Staniloae C. Predictors of left ventricular recovery in a cohort of peripartum cardiomyopathy patients recruited via the internet. Int J Cardiol. 2012;154(1):27–31.PubMedGoogle Scholar
  41. 41.
    McNamara DM, Elkayam U, Alharethi R, Damp J, Hsich E, Ewald G, Modi K, Alexis JD, Ramani GV, Semigran MJ, Haythe J, Markham DW, Marek J, Gorcsan J 3rd, Wu WC, Lin Y, Halder I, Pisarcik J, Cooper LT, Fett JD, Investigators I. Clinical outcomes for peripartum cardiomyopathy in North America: results of the IPAC study (Investigations of Pregnancy-Associated Cardiomyopathy). J Am Coll Cardiol. 2015;66(8):905–14.PubMedPubMedCentralGoogle Scholar
  42. 42.
    Pearson GD, Veille JC, Rahimtoola S, Hsia J, Oakley CM, Hosenpud JD, Ansari A, Baughman KL. Peripartum cardiomyopathy: national heart, lung, and blood institute and office of rare diseases (National Institutes of Health) workshop recommendations and review. JAMA. 2000;283(9):1183–8.PubMedGoogle Scholar
  43. 43.
    Forster O, Hilfiker-Kleiner D, Ansari AA, Sundstrom JB, Libhaber E, Tshani W, Becker A, Yip A, Klein G, Sliwa K. Reversal of IFN-gamma, oxLDL and prolactin serum levels correlate with clinical improvement in patients with peripartum cardiomyopathy. Eur J Heart Fail. 2008;10(9):861–8.PubMedGoogle Scholar
  44. 44.
    Walenta K, Schwarz V, Schirmer SH, Kindermann I, Friedrich EB, Solomayer EF, Sliwa K, Labidi S, Hilfiker-Kleiner D, Bohm M. Circulating microparticles as indicators of peripartum cardiomyopathy. Eur Heart J. 2012;33(12):1469–79.PubMedGoogle Scholar
  45. 45.
    Halkein J, Tabruyn SP, Ricke-Hoch M, Haghikia A, Nguyen NQ, Scherr M, Castermans K, Malvaux L, Lambert V, Thiry M, Sliwa K, Noel A, Martial JA, Hilfiker-Kleiner D, Struman I. MicroRNA-146a is a therapeutic target and biomarker for peripartum cardiomyopathy. J Clin Invest. 2013;123(5):2143–54.PubMedPubMedCentralGoogle Scholar
  46. 46.
    Sliwa K, Forster O, Libhaber E, Fett JD, Sundstrom JB, Hilfiker-Kleiner D, Ansari AA. Peripartum cardiomyopathy: inflammatory markers as predictors of outcome in 100 prospectively studied patients. Eur Heart J. 2006;27(4):441–6.PubMedGoogle Scholar
  47. 47.
    Hilfiker-Kleiner D, Kaminski K, Podewski E, Bonda T, Schaefer A, Sliwa K, Forster O, Quint A, Landmesser U, Doerries C, Luchtefeld M, Poli V, Schneider MD, Balligand JL, Desjardins F, Ansari A, Struman I, Nguyen NQ, Zschemisch NH, Klein G, Heusch G, Schulz R, Hilfiker A, Drexler H. A cathepsin D-cleaved 16 kDa form of prolactin mediates postpartum cardiomyopathy. Cell. 2007;128(3):589–600.PubMedGoogle Scholar
  48. 48.
    Bajou K, Herkenne S, Thijssen VL, D’Amico S, Nguyen NQ, Bouche A, Tabruyn S, Srahna M, Carabin JY, Nivelles O, Paques C, Cornelissen I, Lion M, Noel A, Gils A, Vinckier S, Declerck PJ, Griffioen AW, Dewerchin M, Martial JA, Carmeliet P, Struman I. PAI-1 mediates the antiangiogenic and profibrinolytic effects of 16 K prolactin. Nat Med. 2014;20(7):741–7.PubMedGoogle Scholar
  49. 49.
    Stapel B, Kohlhaas M, Ricke-Hoch M, Haghikia A, Erschow S, Knuuti J, Silvola JM, Roivainen A, Saraste A, Nickel AG, Saar JA, Sieve I, Pietzsch S, Muller M, Bogeski I, Kappl R, Jauhiainen M, Thackeray JT, Scherr M, Bengel FM, Hagl C, Tudorache I, Bauersachs J, Maack C, Hilfiker-Kleiner D. Low STAT3 expression sensitizes to toxic effects of beta-adrenergic receptor stimulation in peripartum cardiomyopathy. Eur Heart J. 2017;38(5):349–61.Google Scholar
  50. 50.
    Toescu V, Nuttall SL, Martin U, Kendall MJ, Dunne F. Oxidative stress and normal pregnancy. Clin Endocrinol. 2002;57(5):609–13.Google Scholar
  51. 51.
    Habedank D, Kuhnle Y, Elgeti T, Dudenhausen JW, Haverkamp W, Dietz R. Recovery from peripartum cardiomyopathy after treatment with bromocriptine. Eur J Heart Fail. 2008.Google Scholar
  52. 52.
    Meyer GP, Labidi S, Podewski E, Sliwa K, Drexler H, Hilfiker-Kleiner D. Bromocriptine treatment associated with recovery from peripartum cardiomyopathy in siblings: two case reports. J Med Case Rep. 2010;4:80.PubMedPubMedCentralGoogle Scholar
  53. 53.
    Haghikia A, Podewski E, Berliner D, Sonnenschein K, Fischer D, Angermann CE, Bohm M, Rontgen P, Bauersachs J, Hilfiker-Kleiner D. Rationale and design of a randomized, controlled multicentre clinical trial to evaluate the effect of bromocriptine on left ventricular function in women with peripartum cardiomyopathy. Clin Res Cardiol. 2015;104(11):911–7.PubMedPubMedCentralGoogle Scholar
  54. 54.
    Arrigo M, Blet A, Mebazaa A. Bromocriptine for the treatment of peripartum cardiomyopathy: welcome on BOARD. Eur Heart J. 2017;38(35):2680–2.PubMedGoogle Scholar
  55. 55.
    Hilfiker-Kleiner D, Haghikia A, Berliner D, Vogel-Claussen J, Schwab J, Franke A, Schwarzkopf M, Ehlermann P, Pfister R, Michels G, Westenfeld R, Stangl V, Kindermann I, Kuhl U, Angermann CE, Schlitt A, Fischer D, Podewski E, Bohm M, Sliwa K, Bauersachs J. Bromocriptine for the treatment of peripartum cardiomyopathy: a multicentre randomized study. Eur Heart J. 2017;38(35):2671–9.PubMedPubMedCentralGoogle Scholar
  56. 56.
    Sliwa K, Forster O, Tibazarwa K, Libhaber E, Becker A, Yip A, Hilfiker-Kleiner D. Long-term outcome of peripartum cardiomyopathy in a population with high seropositivity for human immunodeficiency virus. Int J Cardiol. 2011;147(2):202–8.PubMedGoogle Scholar
  57. 57.
    Duncker D, Haghikia A, Konig T, Hohmann S, Gutleben KJ, Westenfeld R, Oswald H, Klein H, Bauersachs J, Hilfiker-Kleiner D, Veltmann C. Risk for ventricular fibrillation in peripartum cardiomyopathy with severely reduced left ventricular function-value of the wearable cardioverter/defibrillator. Eur J Heart Fail. 2014;16(12):1331–6.PubMedGoogle Scholar
  58. 58.
    Elkayam U, Tummala PP, Rao K, Akhter MW, Karaalp IS, Wani OR, Hameed A, Gviazda I, Shotan A. Maternal and fetal outcomes of subsequent pregnancies in women with peripartum cardiomyopathy. N Engl J Med. 2001;344(21):1567–71.PubMedGoogle Scholar

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© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Denise Hilfiker-Kleiner
    • 1
    Email author
  • Johann Bauersachs
    • 1
  • Karen Sliwa
    • 2
    • 3
  1. 1.Department of Cardiology and AngiologyMedical School HannoverHannoverGermany
  2. 2.Hatter Institute for Cardiovascular Research in Africa & IDM, SA MRC Cape Heart GroupUniversity of Cape TownCape TownSouth Africa
  3. 3.Soweto Cardiovascular Research UnitUniversity of the WitwatersrandJohannesburgSouth Africa

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