Cardiac Case: 38-year-old Woman with Shortness of Breath and Inability to Lie Flat after Childbirth

00:00 A cardiology consultation is requested for a 38-year-old woman who became short of breath several days after delivering her 6th child? She had been previously well and her earlier 5 pregnancies were without complication.

00:14 The patient states that she cannot lie flat at night because lying flat makes her very short of breath and she denies any previous cardiovascular problems or symptoms.

00:24 On physical exam, her blood pressure is low at 92/70 mmHg, heart rate is elevated at 98/min, and her respiratory rate is elevated at 21/min. Her peripheral oxygen saturation is low, abnormally low at 89%, should be well over 90 and her jugular venous pressure is elevated at 12 cm suggesting right atrial elevation of pressure.

00:48 She has crackles halfway up the back so that's pulmonary congestion often due to heart failure and she has a grade 2/6 blowing holosystolic murmur at the apex suggesting mitral regurgitation.

01:01 So that would be, here's normal, lub-dub, lub-dub, and here's the murmur at the apex, lub-shshdub, lub-shshdub, lub-shshdub, or it could be, lub-whoo-dub, lub-whoo-dub, lub-whoo-dub.

01:17 And she has 2+ pitting edema suggesting left ventricular failure.

01:21 So what's critical here? First of all, she has dyspnea. Lower down she has orthopnea.

01:29 That is, she can't lie flat without getting short of breath. She has tachycardia.

01:34 She has an elevated respiratory rate. She has an abnormal oxygen saturation.

01:39 She has an elevated jugular venous pressure, again, suggesting a right heart failure.

01:45 And she has lots of fluid in her chest as well as a murmur that sounds like mitral regurgitation and also, edema at the periphery suggesting heart failure.

01:57 And we do an echocardiogram as the first test and it shows a dilated hypo-contractile left ventricle.

02:05 When you do the motion study, the left ventricular ejection fraction markedly reduced to 22%, should be more than 50%. The diagnosis is post-partum, also called peripartum, dilated cardiomyopathy.

02:19 It's uncommon in industrialized country, much more common in third-world countries were excellent pre-partum care is often not got and where nutritional deficiencies may also occur.

02:33 And the peripartum or post-partum cardiomyopathy can occur during the last trimester pregnancy or a number of days after delivery.

02:41 So the therapy of course, diuretics to get rid of the excess fluid, long term beta blockade, hopefully they help the heart recover, angiotensin converting enzyme inhibition or angiotensin receptor blocker to blockade the renin angiotensin system often combined with mineralocorticoid blockades, spironolactone all of which are attempting to decrease the tendency to hold onto salt and water.

03:06 For patients such as this one with heart failure with reduced ejection fraction, of course referred to as HfRef, as we talk about.

03:14 If patients have contraindications to any of the renin angiotensin system antagonists, an alternative is hydralazine plus a long-acting nitrate.

03:23 In patients who still have symptomatic heart failure, secondary therapies may be added in addition to the initial medications.

03:30 These include mineralocorticoid receptor antagonists such as spironolactone that I just mentioned, or SGLT2 Inhibitors.

03:39 If further secondary therapies are needed, newer medications include verciquat or ivabradine.

03:47 and as we talkt about befor Vericiguat is indicated for people with New York heart association class 2 to 4 heart failure with an ejection fraction less than 45% who were either hospitalized in the last 6 months or required outpatient IV diuretics.

04:04 Ivabradine is a newer class of medication called a hyperpolarization-activated cyclic nucleotide-gated (HCN) channel blocker It is indicated for patients with an ejection fraction 35% or less who are in sinus rhythm with a resting heart rate at least 70 beats a minute or more despite beta blockers or with contraindications to beta blockers or contra indications to beta blockers.

04:29 Ivabradine works by slowing the sinus node by slowing the spontaneous ingress of sodium through the so-called funny channel into the sinus node cells.

04:42 And with continued medical therapy, most patients recover their left ventricular function comes back to normal or near normal.

04:50 There's about a 20% chance of recurrence of this if she becomes pregnant again and so we usually recommend that the patient not become pregnant again.

04:59 It's more common in women that had many pregnancies like this lady so certainly at this point, it would be suggested that she have tubal ligation.