Pharmacologic and Device Therapy for Peripartum Cardiomyopathy

Laliberte B, Reed BN, Ather A, et al.
Safe and Effective Use of Pharmacologic and Device Therapy for Peripartum Cardiomyopathy. Pharmacotherapy 2016;36:955-70.

The following are 10 key points from this review, which is intended to inform clinicians about the safety and efficacy of pharmacologic and device therapy for the management of peripartum cardiomyopathy:

  1. Peripartum cardiomyopathy is defined as new-onset left ventricular (LV) dysfunction during the last few months of pregnancy or immediately postpartum. Although associated with a significant risk of mortality, most patients recover full LV function.
  2. Despite limited evidence, the management of peripartum cardiomyopathy hinges on guideline-directed medical therapy as indicated for other forms of heart failure (HF) with reduced LV function. This presents unique challenges given the potential for fetal risk during pregnancy and postpartum concerns in lactating women.
  3. Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin-receptor blockers (ARBs), both prior Food and Drug Administration Pregnancy Category D drugs, have known teratogenic effects with exposure in the second and third trimester. However, several small studies have demonstrated successful use of these agents, albeit mostly in the postpartum period. Data are sparse on the use of ACEIs in lactating women; no data exist for ARBs.
  4. The demonstrated safety of using labetalol in pregnant women with hypertension is reassuring for beta-blockers as a class. Those beta-blockers indicated for HF (bisoprolol, carvedilol, and metoprolol succinate [all Category C]), are generally considered safe during pregnancy and lactation. It should be noted, however, that beta1-selective agents (bisoprolol and metoprolol) should be favored over carvedilol due to its potential beta2-mediated anti-tocolytic effects.
  5. Diuretics are essential to manage symptoms; however, diuretic use in patients with peripartum cardiomyopathy can reduce placental blood flow. Additionally, diuretics may potentially decrease the production of breast milk, but they are considered generally safe to use in lactating women. Of note, only torsemide and metolazone previously received a Category B pregnancy rating; other diuretics were Category C.
  6. Aldosterone antagonists have not been generally studied for use in pregnancy given the known teratogenic and antiandrogenic effects of spironolactone (Category C) in rodents. These agents should be withheld until after delivery. Eplerenone (Category B) is preferred because it lacks the same antiandrogenic effects of spironolactone, although no data exist on its use in lactating women.
  7. Hydralazine and isosorbide dinitrate are preferred over ACEIs and ARBs in the antepartum period, but patients with peripartum cardiomyopathy should be transitioned to an ACEI or ARB after delivery. Those with peripartum cardiomyopathy and significant renal impairment may, however, remain on hydralazine and isosorbide dinitrate. Hydralazine is safe for use in lactating women, but no data exist for isosorbide dinitrate.
  8. Digoxin is safe to use during pregnancy and in lactating women but remains a second-line option to improve symptoms and decrease hospitalizations. Of note, digoxin remains a safe and effective rate control agent for the treatment of fetal supraventricular tachycardia because it crosses the placenta.
  9. As expected, more recently available HF therapies (sacubitril/valsartan and ivabradine) have limited data for their use in both pregnant and lactating women. The same fetal risk of ARB exposure during the second and third trimester should remain a concern with sacubitril/valsartan.
  10. The indication for the use of an implantable-cardioverter defibrillator remains the same in patients with peripartum cardiomyopathy; however, one must remember that most of these patients will fully recover their LV function. Data demonstrating successful use of implantable-cardioverter defibrillators in this population are available. Alternatively, wearable cardioverter-defibrillator devices may be considered.

Keywords: Adrenergic beta-Antagonists, Angiotensin Receptor Antagonists, Angiotensin-Converting Enzyme Inhibitors, Bisoprolol, Cardiomyopathies, Defibrillators, Defibrillators, Implantable, Digoxin, Diuretics, Heart Defects, Congenital, Heart Failure, Hydralazine, Hypertension, Isosorbide Dinitrate, Labetalol, Lactation, Metolazone, Metoprolol, Milk, Human, Mineralocorticoid Receptor Antagonists, Peripartum Period, Placenta, Pregnancy, Pregnancy Trimester, Third, Spironolactone, Tachycardia, Supraventricular, Tocolytic Agents

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