ABC | Volume 114, Nº5, May 2020

Statement Brazilian Cardiology Society Statement for Management of Pregnancy and Family Planning in Women with Heart Disease – 2020 Arq Bras Cardiol. 2020; 114(5):849-942 thrombus or systemic embolism, as well as in paroxysmal or persistent AF. 222 The proposed schedule shows that safe doses with good tolerance and efficacy are 2.5 mg twice daily for 2 weeks, followed by 2.5 mg once daily for 6 weeks for bromocriptine; and 1 mg single dose for cabergoline for its prolonged effect from 14 to 21 days. 218-219 The abbreviation BOARD has been proposed for chronic treatment of patients with PPCM following delivery. The abbreviation stands for B romocriptine, O ptimization of HF therapy, A nticoagulation, Vaso R elaxants, and D iuretics. 218 Bromocriptine treatment must always be accompanied by anticoagulation with heparin (LMWH or UFH), at least in prophylactic dosages; in patients with intracardiac thrombus detected by imaging or evidence of systemic embolism, as ell as in patients with paroxysmal or persistent atrial fibrillation. 222 Regarding the non-pharmacological treatment of PPCM, ICD, cardiac resynchronization, ventricular assist devices, and cardiac transplantation are considered. 220-222 ICD has been considered for primary prevention of sudden death, following guidelines for patients with ventricular EF below 35%. Wearable defibrillator cardioverter is an alternative during the first months following diagnosis with PPCM, considering that most of these patients recover ventricular function 6 months after the acute phase of the disease. Cardiac resynchronization may be proposed 6 months after the onset of the disease, in accordance with conventional indication criteria, or be it, advanced HF, NYHA FC III-IV with optimized treatment, sinus rhythm, EF below 35%, QRS > 150 ms, or QRS > 120 ms with desynchronization on echo or magnetic resonance. Left ventricular assist devices may be an option in critically severe patients as a “bridge to transplant” or a “bridge to recovery.” Cardiac transplant is indicated in approximately 10% of PPCM cases in patients who do not recover after 12 months with mechanical circulatory support. During long-term clinical follow-up, the following recommendations should be followed: 221 1. If the cardiac function does not improve, maintain beta-blocker, ACEI or ARB; spironolactone if EF < 40%, ivabradine if heart rate > 75 bpm, with a maximum dose of beta-blocker (reaching heart rate < 60 bpm); diuretics if there is edema / pulmonary congestion; 2. If ventricular function shows complete and sustained recovery, supported by bi-annual echocardiographic follow-up, maintain pharmacological treatment (beta‑blocker, ACEI, spironolactone) for at least 6 months and diuretics only if there are symptoms of congestion or lower limb edema; during the period between 6 and 12 months thereafter, discontinue spironolactone and ivabradine (if in use), but continue beta-blocker and ACEI/ARB for at least 6 months following discontinuation of spironolactone; after 12 months, gradually reduce and discontinue ACEI/ARB, and maintain beta-blocker for 6 more months; after 18 months, suspension of the beta- blocker is controversial, because some studies claim that it should be maintained for at least 5 years; 3. Advising against subsequent pregnancy in patients who have completely recovered left ventricular systolic function following PPCM is controversial, giving that there is no conclusive evidence supporting this advice in medical practice. 218 The following points resume recommendations for practice in cases of acute HF: 208,222 1. Transcutaneous monitoring of oxygen saturation; 2. Oxygen therapy: oxygen saturation < 90% (pulse oximetry); PaO 2 < 60 mmHg (arterial-blood gas test); 3. Endotracheal intubation performed in acute respiratory insufficiency with hypoxemia (PaO 2 < 60 mmHg), hypercapnia (PaCO 2 > 50 mmHg), and acidosis (pH < 7.35); 4. Diuretics if there are signs of congestion (furosemide, 20 to 40 mg) in an intermittent bolus or a continuous infusion; 5. Vasodilators if SAP > 110 mmHg; intravenous nitroglycerin, at an initial dose of 10 to 20 μg/min, up to a maximum of 200 μg/min; 6. Inotropic agents (dobutamine, dopamine, levosimendan, phosphodiesterase III (PDE III) inhibitors in hypotensive patients (SBP < 90 mmHg) and/or signs of low cardiac output; experimental evidence and clinical experience suggest that catecholamines such as dobutamine are less favorable in patients with PPCM due to metabolic impairment levosimendan can be considered as the preferred inotropic agent, with continuous infusion of 0.1 µg/kg/h for 24 h without an initial bolus dose for patients with severe PPCM; if levosimendan is not available, dobutamine is the other option, while adrenaline should be avoided. 7. Vasopressor agents for cardiogenic shock; noradrenaline should be the first-line vasopressor. 8. Anticoagulation with full-dose LMWH, provided there are no contraindications; 9. Mechanical circulatory support as a “bridge to decision” for cardiac transplantation. 3.3.7.1. Key Points • The etiopathogenesis of PPCMhas yet to be fully clarified; • Immediate diagnosis and treatment at the onset of symptoms are fundamental to ventricular recovery; • The use of prolactin inhibitors (bromocriptine or cabergoline), combined with optimized treatment for HF is differential for the recovery of ventricular function; • Approximately 50% of patients with PPCM recover myocardial function within 6-month period with therapy for HF; • Even if ventricular function is recovered, follow up should be periodic for at least 5 to 10 years, following diagnosis; • As a result of the lack of evidence regarding the actual recurrence of PPCM during subsequent gestations, there is no justification for advising against conception in patients who have truly recovered ventricular function; • Patients with PPCM who have received transplantation have an immediate and late postoperative prognosis like that of patients with other forms of dilated cardiomyopathy. 886