ABC | Volume 115, Nº1, July 2020

Editorial Avila & Carvalho COVID-19: pregnancy and heart disease Arq Bras Cardiol. 2020; 115(1):1-4 COVID-19 can result in cardiac injury by multiple mechanisms, resulting in an extreme inflammatory response with endothelial injury and myocarditis. 14 During pregnancy and the postpartum period, acute heart failure should be considered in some circumstances, such as peripartum cardiomyopathy, viral myocarditis, and noncardiogenic pulmonary edema. Pulmonary edema is also seen in healthy pregnant women, as a consequence of major changes in intravascular volume during labor and after delivery. Likewise, hemodynamic changes in pregnancy cause an increase in the gradient across the stenotic mitral valve and could lead to pulmonary congestion. Congenital cyanotic cardiopathy, obstructive injuries of the left side of the heart or serious systemic ventricular dysfunction present a greater risk of cardiac complications in pregnant women . The fall in systemic vascular resistance worsens hypoxemia in pregnant women with pulmonary hypertension and with uncorrected tetralogy of Fallot Systemic coagulopathy is a critical aspect of morbidity and mortality in COVID-19. 14 The hypercoagulable state (Table 1) of pregnancy increases the risk of thromboembolism in women with heart disease. In this scenario, the combination of COVID-19 and mechanical valve prosthesis or atrial fibrillation in rheumatic valve disease increases the risk of thromboembolic events in pregnant women . It is worth noting that, as D-dimer levels increase as pregnancy progresses, it is not a good marker for the diagnosis of thromboembolism in pregnancy. Despite radiation exposure, chest computed tomography and complementary angiography should be indicated in pregnant women with heart disease and COVID-19, when pulmonary thromboembolism is suspected. Systemic inflammation and coagulopathy in COVID-19 increase the risk of atherosclerotic plaque rupture and acute myocardial infarction. 14 The significant implication of SARS- CoV-2 infection for the cardiovascular system is evidenced by acute myocardial injury (high levels of highly sensitive troponin I and/or new ECG/echocardiogram abnormalities), complex cardiac arrhythmias, and cardiac arrest. During pregnancy, acute coronary syndromes are not common. However, infections, especially in the postpartum period, are a risk factor for myocardial infarction . The most frequent causes of myocardial infarction during pregnancy are spontaneous coronary artery dissection, atherosclerosis, coronary thrombosis, and normal arteries on angiography with impaired coronary microcirculation According to recent studies, angiotensin-converting enzyme 2 (ACE2) is a functional receptor of SARS-CoV-2. 15 The renin-angiotensin system is a key player in blood pressure regulation, and ACE2 plays a critical role in cardiovascular physiology control in pregnant women. Angiotensin-(1-7) is significantly elevated in healthy pregnant women as compared to nonpregnant ones. In preeclampsia, plasma angiotensin levels (1-7) are reduced and plasma angiotensin II is consistently elevated, which contributes to the development of hypertension in these pregnant women. Moreover, pregnant women with chronic hypertension are at risk for preeclampsia or HELLP syndrome. Therefore, the relationship between positive regulation of ACE2 and SARS-CoV-2 in pregnancy requires further studies. Finally, there are currently no data available on the outcome of pregnancy in patients with heart disease or arterial hypertension and COVID-19. However, those patients must be considered a high-risk group. In view of the lack of specific therapy and vaccine for COVID-19, we have to be prepared to prevent and treat cardiovascular complications during pregnancy. 13 Integrated and multidisciplinary care should be aimed at optimizing therapy, guiding patients on the risks of COVID-19, and treating them in an occasional infection by SARS-CoV-2. The severe consequences of COVID-19 compounded by the possible complications experienced by pregnant women with heart disease or arterial hypertension could result in poor maternal outcome and uncertain prognosis. 1. World Health Organization. (WHO) Coronavirus disease (COVID-19) Pandemic. [Cited in 2020 Apr 23] Available from: https://www.who.int/ emergencies/diseases/novel-coronavirus-2019. 2. Brasil.Ministério da Saúde. Secretaria de Atenção Especializada à Saúde. Protocolo de manejo clínico da Covid-19 na Atenção Especializada. [Citado em19abr2020]Disponívelem: https://portalarquivos.saude.gov.br/images/ pdf/2020/April/14/Protocolo-de-Manejo-Cl--nico-para-o-Covid-19.pdf 3. Meljer WJ, van Noortwijk AG, Bruinse HW, Wensing AM. Influenza virus infection in pregnancy. A review. Acta Obstet Gynecol Scand. 2015 Aug;94(8):797-819. 4. Sanghavi M, Rutherford JD. Cardiovascular physiology of pregnancy. Circulation. 2014;130(12):1003-8. 5. Cui C, Yang S, Zhang J, Wang G, Huang S, Li A, et al. Trimester-specific coagulation and anticoagulation reference intervals for healthy pregnancy. Thromb Res. 2017 Aug;156:82-6. 6. Hegewald MJ. Respiratory physiology in pregnancy. Clin Chest Med. 2011;32(1):1-13. 7. Kwon JY, Romero R, Mor G. New insights into the relationship between viral infection and pregnancy complications. Am J Reprod Immunol. 2014 May; 71(5):387-90. 8. Schwartz DA, Graham AL. Potential Maternal and Infant Outcomes from (Wuhan) Coronavirus 2019-nCoV Infecting Pregnant Women: Lessons from SARS, MERS, and Other Human Coronavirus Infections. Viruses. 2020 Feb 10;12(2):194. 9. ZaighamM,AnderssonO.MaternalandperinataloutcomeswithCOVID-19 : A systematic review of 108 pregnancies Acta Obstetric Gynecol Scand. 2020;00:1-7 10. YanJ,GuoJ,FanC,JuanJ,YuX,LiJ,etal.Coronavirusdisease2019COVID-19) inpregnantwomen:areportbasedon116casesAm JObstetrGynecol.2020 11. Zhu H, Wang L, Fang C, Peng S, Zhang L, Chang G, et al. Clinical analysis of 10 neonates born to mothers with 2019-nCoV pneumonia. Transl Pediatr. 2020;9(1):51–60. 12. Fan C, Lei D, Fang C, Li C, Wang M, Liu Y, et al. Perinatal transmission of COVID_19 associated SARS-Cov2: Should we worry? Clin Infect Dis,2020 Mar 1y.ciaa226. 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