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 or signs of ventricular dysfunction. There are no high- quality data defining how much time pregnancy should be delayed following acute coronary syndrome. However, the recommendation of 12 months seems reasonable; it should be individualized according to comorbidities, cardiovascular status, and need for medical therapy. 3.4.1. Key Points • The growing incidence of IHD during pregnancy is due to higher maternal age and the growing presence of risk factors; • The incidence of AMI without ST-segment elevation is higher during pregnancy, and the anterior descending artery is the most affected; • The clinical picture of coronary artery dissection seems to be more severe during gestation, in comparison with the general population; • Coronary vasospasm may occur as a consequence of obstetric medications; • Symptoms, ECG, elevated serum troponin, and alterations on echo define diagnosis of acute coronary syndrome; • Coronary cineangiography should be indicated to define diagnosis and make percutaneous treatment possible; • Treatment follows the general rules, with eventual restrictions on gestation; 3.5. Dyslipidemia 3.5.1. Lipid Changes During pregnancy, a substantial increase occurs in plasma concentration of lipoproteins, as result of the increase in circulating estrogen and progesterone. Triglycerides increase 2- or 3-fold in relation to pre-gestational values, reaching their peak by the end of gestation, with a progressive return to baseline values at the end of the postpartum period. In the same manner, there is a progressive increase in total cholesterol levels, corresponding to 2- to 5-fold before pregnancy values. Their decrease is slightly slower than that of triglycerides, and they may take longer than 6 weeks after delivery to normalize. 228 Lipoprotein fractions also present qualitative increase of high density lipoprotein cholesterol (HDL-c), low density lipoprotein cholesterol (LDL-c) and amount of triglycerides. The HDL-c has slightly different behavior from total cholesterol and triglycerides, because it raises a progressive values at 24 th week, of 50% in comparison with preconception period. Subsequently, it presents a drop, equivalent to 15% higher than pre-gestational values until the end of pregnancy. 228 LDL-c levels increase in synchronization with total cholesterol. However, they showed decrease and may fall after the eighth week postpartum. The factor responsible for these alterations in lipoproteins is the hormone estrogen. The drop in HDL-c after week 24 is understood by the increase in plasma concentration of insulin, which represents an increase in insulin resistance. It is, therefore possible to conclude that HDL-c levels are more related to estrogen levels during the first phase of gestation and to insulin during the second phase. It isrecommended that lipid profile test by postponed to, at least, 4 to 6 weeks after gestation, especially in women without previous alterations. In an update to the Brazilian Guidelines on Dyslipidemia and Atherosclerosis Prevention, the recommendations for women of fertile age with dyslipidemia include dietary orientation and adoption of a healthy lifestyle, in addition to weight control, physical activity, and ceasing tobacco use. 229 Therapy with statins should be avoided in women of fertile age who plan to become pregnant (class II-A; C). Gestational hypertriglyceridemia occurs to meet maternal energy demands, as a precursor of hormones for the placenta and to provide cholesterol and essential fatty acids to the fetus. Statin therapy should not be indicated for pregnant women in the second and third trimester or in breastfeeding women (class III-C). This contraindication is due to reports of teratogenicity, although the information available in the literature is inconclusive. 104 Fibrates, ezetimibe, niacin, cholesterolamine and omega-3 are considered to be drugs without contraindication, but cholesterolamine is the only one whose safety has been established. Fibrates may be used in cases of very severe hypertriglyceridemia (plasma level of triglyceride>1,000mg/dL), with risk/benefit analysis for pregnant women (highmaternal and fetal mortality due to acute pancreatitis). However, dietary control should be the treatment of choice for pregnant women (class IIA; C); in extreme cases, apheresis may be recommended. 230 Regarding omega-3 fatty acids, pregnant and breastfeeding women should advised to introduce omega-3-rich fish, from deep water and with low mercury levels, into their diets. Salmon, mackerel, herring, sardines, tuna and trout are recommended. There are no studies on supplementation (capsules) and phytosterols during gestation. Genetic dyslipidemias should be considered, both hypertriglyceridemia with frequent pancreatic complications and familial hypercholesterolemia. Apheresis is a special therapeutic approach to these severe circumstances; in familial cases, selective LDL-apheresis is used. 231 Until recently it was accepted that dyslipidemia during pregnancy should be considered physiological, to the extent that lipid profile testing is not part of the prenatal routine. Recently, however, fatty striae have been described in the aorta of dyslipidemic mother fetuses. Based on these observations, it has been suggested that maternal cardiometabolic dysfunction may not only contribute to long-term maternal effects, but it may also lead to a risk of atherosclerosis in future generations. These considerations suggest that diagnosis and treatment of dyslipidemias should be performed prior to conception, and they should continue during gestation and the postpartum period. 232 3.5.2. Key Points • Increases occur in triglycerides and cholesterol during pregnancy; • The use of statins is not recommended, although there is some controversy regarding their teratogenic effects; • Maternal dyslipidemia may induce fetal atherosclerosis and atherosclerosis in future generations. 888