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 Figure 12 – Algorithm for diagnosis when there is clinical suspicion of acute heart failure. ER: emergency room. Adapted from Rohde et al., 2018. 345 Patients with suspected acute HF 30 minutes Diagnostic flowchart Obstetric and fetal evaluation Consider therapeutic delivery in accordance with obstetric criteria Risk stratification in the ER Inadequate response to admission treatment without decompensated comorbidity Good response to admission treatment without decompensated comorbidity 60-120 minutes High Risk Low risk Discharge within 72 hours Intensive care units Admission treatment in the ER Intensive care units Intermediate risk Differential diagnosis – Acute myocardial infarction – Preexisting heart disease – Peripartum cardiomyopathy – Myocarditis – Pulmonary embolism Patients with high immediate risk to life – Respiratory insufficiency – Cardiogenic shock – Acute pulmonary edema – Tachyarrhythmia or bradycardia – Acute mechanical cause – Hypertensive emergency – Stroke/mental confusion/disorientation – Decompensated comorbidity • PPCM: dyspnea during the last month of gestation or, more frequently, after delivery, with significant elevation in levels of BNP and new systolic dysfunction in the left and right ventricles. CMR is important to determine diagnosis; 222 • Thromboembolism: Dyspnea is associated with pleuritic chest pain. Levels of troponin and BNP are elevated, and right ventricular dysfunction and PH are signs of greater severity of this event. It is worth emphasizing that sensitivity and negative predictive value of D-dimer are limitedwhen there is suspicion of PVS during pregnancy; 381 • Myocarditis: Dyspnea is associated with unspecific symptoms related to viral infection. Troponin may be elevated (myocardial inflammatory processes increase cellular release), and echo may demonstrate segmental akinesis or diffuse hypokinesis. CMR with identification of myocardial edema or mesocardial fibrosis reinforce diagnosis. 382,383 During clinical evaluation, it is fundamental to determine hemodynamic profile. In patients classified as profile B (wet and warm), volume adjustment with diuretics and vasodilators, in the absence of hypotension and shock, should be considered sparingly, keeping the formal contraindication to the use of ACEI and ARB in mind and giving preference to the use of nitrates and hydralazine, in combined therapy, whenever possible. Loop diuretics are safe. Furosemide is the most commonly used, at an initial dose of 20 to 40 mg, with the possibility of optimization, depending on previous chronic use, diuretic response, and improvement of dyspnea and hypoxemia. 384 Fetal risks are consequent to reduced placental flow due to volume adjustment beyond what is necessary. In more severe patients or cases of acute pulmonary edema, without hypotension or shock, nitroglycerin or sodium nitroprusside is used in continuous infusion, preferably guided by invasive arterial monitoring. Doses and infusion rates are described in Table 42. Continuous fetal monitoring should also be performed, seeing that the abrupt reduction in maternal arterial pressure may compromise fetal vitality. Non-invasive ventilation (NIV) support with positive pressure is indicated for all patients with peripheral arterial saturation < 90% and respiratory distress or discomfort who do not improve with oxygen therapy. 369 It is also indicated for patients with acute pulmonary edema, given that, in non‑pregnant women, it is known to have benefits for reducing the need for invasive mechanical ventilation support. 348 In patients with symptomatic hypotension, signs of low cardiac output with organic dysfunction, or cardiogenic shock, there is a need for inotropic agents and, in some cases, association with vasoconstrictors, similarly to non-pregnant patients. Dobutamine is the most widely used inotropic agent, because it promotes a dose-dependent increase in cardiac output, even though its arrhythmogenic effect is limiting, and it presents lower efficacy in cases of chronic beta-blocker use. Milrinone, in addition to increasing cardiac output, is able to reduce peripheral and pulmonary resistance. It is, therefore, indicated in patients with congenital heart disease and PH. 344 Levosimendan presents a positive inotropic effect, due to its vasodilatory action, however, it should be used with greater caution in pregnant women. Table 43 shows drugs and their recommended doses for treatment of AHF during pregnancy. In patients with AHF due to PPCM, as discussed in section 3.3.7, levosimendan is preferable, keeping the biomolecular 918