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 and it has the best reversibility rate. The use of amiodarone should be excluded to isolated situations, when cases are refractory and ventricular arrhythmia recurs following electrical cardioversion, and it is necessary to be aware of its dose- dependent effects on the fetus. 391 ICD implantation in indicated patients is approved during pregnancy when it ensures better prognosis during delivery and the postpartum period. 392 5.7.3. Acute Myocardial Infarction AMI, which is uncommon during pregnancy, is potentially fatal. Over the past decades, its incidence has been found to increase, notwithstanding reduced maternal mortality due to the issue during gestation. 224 In general, practice for treating AMI during gestation follows the same recommendations as the general population, including revascularization with stent angioplasty or surgical revascularization. 393 Multiprofessional care includes obstetric evaluation and continuous monitoring of the fetus, with evaluation of fetal vitality and cardiotocography. Clinical treatment of AMI during pregnancy considers the following: 394 • Oxygen therapy: nasal O 2 catheter, 2 to 3 L/min; • Pain control: Morphine sulfate is considered to be safe and effective, but it may lead to respiratory depression in the fetus if administered near delivery; • Nitrates: Attention should be paid to the risk of maternal hypotension and consequent low uteroplacental flow; • Beta-blockers: metoprolol, carvedilol, or propranolol. Fetal monitoring with cardiotocography is recommended to control uterine dynamics and fetal heartbeat; • Aspirin: low doses (< 150 mg); • Clopidogrel may be used, but it should be suspended 7 days before delivery; • Heparins: UFH and LMWH are used according to indications. Fondaparinux should only be used when heparins are contraindicated. Indicated treatment of AMI with ST-segment elevation is coronary reperfusion, as early as possible, 389,395 by means of either thrombolytic 396 drugs or, preferably, primary coronary angioplasty with stents. Thrombolytics should be restricted to cases where the hemodynamic room is not available in a timely manner. Restrictions to its use are due to the risk of placental hemorrhage. If percutaneous angioplasty is indicated, there is still controversy regarding the preference of conventional stents to drug-eluting stents. 52 Risk stratification of patients with acute coronary syndrome without ST segment elevation is indicated, in the same manner as in non-pregnant patients, considering age, vital signs, risk factors, recent or recurrent symptoms, and electrocardiographic and laboratory findings. In low-risk pregnant patients without signs of HF, refractory pain, or electric instability, conservative clinical treatment is indicated. In contrast, in high-risk pregnant patients, invasive stratification during the first 24 to 48 hours following the onset of the acute condition should be prioritized in order to proceed to myocardial revascularization. 396 Spontaneous coronary artery dissection is a frequent cause of AMI in women, it should, therefore, be the first hypothesis when faced with an acute ischemic event during gestation. Treatment should followconventional recommendedmeasures. 397 5.7.4. Acute Aortic Syndrome Most acute aortic syndromes occur in women with diseases predating gestation, but they may also affect patients who were previously healthy. It is estimated that the incidence of dissection of the aorta in the population is from 2.4 to 2.9 out of 100,000 patients yearly, and there appears to exist a strong correlation with pregnancy in women under 40 years of age. 398 Chest pain in women with aortic disease requires investigation with angiotomography of the aorta, in order to rule out suspicion of acute dissection of the aorta. In pregnant patients with type A dissection, with involvement of the ascending aorta, there is an indication for emergency cardiac surgery, in addition to pressure and heart rate control. The procedure should take place in conjunction with a multiprofessional team in a tertiary cardiology center, and cesarean delivery is indicated when the fetus is viable, followed by correction of the dissection. In situations where the fetus is not viable, cardiovascular surgery is performed, prioritizing the mother’s life (contemplating that fetal mortality is from 20% to 30%). 399 In women with uncomplicated type B dissection of the aorta, without involvement of the ascending aorta, initial conservative treatment is indicated, maintaining adequate arterial pressure and heart rate control. In the event that there are signs of complication, such as persistent pain, uncontrolled arterial hypertension, progression of dissection, ischemia in a target organ or symptoms of aortic rupture, percutaneous treatment should be considered, even though it has been little described during gestation. 400 Route of delivery should be cesarean once fetal viability has been ensured. 5.7.5. Prosthetic Valve Thrombosis The incidence of thrombosis in mechanical prostheses during pregnancy varies according to the anticoagulation regime utilized. Diagnosis should be considered in previously asymptomatic pregnant women who present dyspnea, chest pain, and symptoms of hypotension. Transesophageal echo is the gold standard examination for definition. 401 Treatment of valve thrombosis during pregnancy or the postpartum period should be the same as that proposed for non-pregnant patients, taking their clinical condition, thrombus size and localization of the affected prosthesis into consideration. 96 Thrombolytic use should be considered in critical patients who would present great risks of death if they underwent surgery, in places where a surgical team is not available, and in the event of thrombosis in the tricuspid or pulmonary valve. The following thrombolytic doses are recommended: streptokinase, 1,500,000 IU for 60 minutes without UFH; or alteplase (rT-PA), 10 mg in a bolus + 90 mg for 90 min with UFH. 151,402 In partially successful cases, i.e., cases that persist with residual thrombi, patients should be referred for surgery 24 hours after thrombolytic infusion has been discontinued. 920