Cardiovascular disease in pregnancy — viva

Stem

Practice viva. The examiner takes you through the obstetric cardiology clinic and labour ward: a risk assessment, a woman with hypertension, a post-partum woman with chest pain, AF in pregnancy and drug choices.

Branch A — Risk assessment

Examiner: How do you assess a woman with heart disease who wants to become pregnant?^[1]

Strong answer:

• ESC 2025 recommends a risk assessment in all women with CVD of childbearing age using the mWHO 2.0 classification (Class I, Level C).^[1]
• mWHO 2.0 updates the 2018 modified WHO classification and integrates CARPREG II modifiers: 1 point for no prior cardiac intervention indicated or late pregnancy assessment; 2 points for ventricular dysfunction, high-risk left-sided valve disease or outflow tract obstruction, pulmonary hypertension, coronary artery disease or high-risk aortopathy; 3 points for prior cardiac event or arrhythmias, baseline NYHA III/IV or cyanosis, or a mechanical valve.^[1]
• Women in class II–III and above should be evaluated and managed by a Pregnancy Heart Team from pre-pregnancy onwards through pregnancy and post-partum (Class I, Level C).^[1]

Follow-up: And for a woman in class IV?^[1]

• ESC 2025 recommends a Pregnancy Heart Team discussion of the high risk of maternal mortality or morbidity and the related high foetal risk, including shared decision-making about termination, with psychological support (Class I, Level C).^[1]
• In Table 6 the class IV average maternal cardiac event rates were 50.3% (van Hagen 2016) and 35.6% (Silversides 2018), and fertility treatment should be avoided in class IV.^[1]

Branch B — Hypertension

Examiner: A woman at 30 weeks has gestational hypertension at 150/96 mmHg on office readings. What do you do?^[1]

Strong answer:

• ESC 2025: in gestational hypertension, starting drug treatment is recommended at systolic BP of 140 mmHg or more or diastolic BP of 90 mmHg or more on office measurement (Class I, Level B), aiming for below 140/90 mmHg (Class I, Level B).^[1]
• ESC 2025 recommends methyldopa (Class I, Level B) and labetalol, metoprolol or dihydropyridine CCBs (Class I, Level C); AHA/ACC 2025 names labetalol and extended-release nifedipine as preferred agents for individuals with hypertension who are planning or in pregnancy (COR 1, LOE A).^[1][5]
• ESC 2025: in gestational hypertension, delivery is recommended at 39 weeks (Class I, Level B).^[1]
• ESC 2025: ambulatory or home BP monitoring should be considered to exclude white-coat and masked hypertension (Class IIa, Level C), and home monitoring may be considered as an adjunct to office readings to detect new-onset hypertension or monitor BP control (Class IIb, Level B).^[1]
• The pre-eclampsia prevention rows are covered in the topic: ESC 2025 low-dose aspirin from weeks 12 to 36/37 at moderate or high risk (Class I, Level A), AHA/ACC 2025 counselling about low-dose aspirin for individuals with hypertension planning or in pregnancy (COR 1, LOE B-R), and ESC 2024 low- to moderate-intensity exercise, in consultation with an obstetrician, in all pregnant women without contraindications, to reduce the risk of gestational hypertension and pre-eclampsia (Class I, Level B).^[1][5][4]

Follow-up: Which drugs must she avoid?^[5]

• ESC 2025 text: ACE inhibitors, ARBs and direct renin inhibitors are strictly contraindicated, and diuretics are not advised in gestational hypertension and pre-eclampsia.^[1]
• AHA/ACC 2025: individuals with hypertension who are planning or in pregnancy should not be treated with atenolol, ACEi, ARB, direct renin inhibitors, nitroprusside or MRA, to avoid fetal harm (COR 3: Harm, LOE C-LD).^[5]

Branch C — Post-partum chest pain

Examiner: A woman 5 days after delivery has chest pain with ST elevation and a troponin rise. What are you thinking?^[1]

Strong answer:

• ST elevation is not normal in pregnancy and warrants urgent attention; the ESC 2025 chest-pain algorithm (Figure 11) covers pregnancy and the first 6 months post-partum, and ESC 2025 recommends managing pregnant women with ACS in the same way as non-pregnant women, including diagnostic investigations and interventions (Recommendation Table 12, Class I, Level C).^[1]
• SCAD is the single most frequent cause of ACS in pregnancy and post-partum (43%), followed by atherosclerosis (27%), coronary embolism (17%) and vasospasm (2%), and more than 70% of pregnancy-associated SCAD occurs early post-partum, most often in the first week.^[1]
• The Fifth Universal Definition of MI (2026) says SCAD should be considered particularly in women under 50 and in pregnancy or the post-partum period, and places it among the acute coronary pathologies of primary MI.^[8]

Follow-up: Angiography shows SCAD and she is stable without ongoing ischaemia. Do you stent?^[1]

• ESC 2025: PCI in SCAD carries more complications, particularly iatrogenic dissection and haematoma extension, so a conservative approach is advised in clinically stable women without active or ongoing ischaemia.^[1]
• ESC 2023 ACS (not specific to pregnancy): PCI in SCAD is recommended only with symptoms and signs of ongoing ischaemia, a large area of myocardium in jeopardy and reduced antegrade flow (Class I, Level C).^[9]
• ESC 2025 adds that evidence favours single antiplatelet therapy with aspirin in conservatively managed SCAD, and low-dose aspirin is recommended as the antiplatelet of choice in pregnancy and lactation when single antiplatelet therapy is indicated (Class I, Level B).^[1]
• She should be carefully counselled about the risk of recurrent events in a subsequent pregnancy (ESC 2025), and ESC 2026 cardiac rehabilitation says tailoring rehabilitation to women should be considered for women with SCAD, to improve enrolment and adherence (Class IIa, Level B1).^[1][12]

Branch D — AF in pregnancy

Examiner: A woman at 26 weeks has new AF with a rapid ventricular rate. She is haemodynamically stable with preserved LVEF and no structural heart disease. How do you treat her?^[1]

Strong answer:

• ESC 2025: i.v. beta-blockers (for example metoprolol; not atenolol) are recommended as the first-line option for acute rate control (Class I, Level C), and i.v. digoxin or verapamil (if LVEF is preserved) should be considered as a second-line option (Class IIa, Level C).^[1]
• Rhythm control is the preferred AF strategy in pregnancy; ibutilide or flecainide may be considered to terminate AF in women without structural heart disease (Class IIb, Level C).^[1]
• The indication for anticoagulation with LMWH before cardioversion, and the need for transoesophageal echocardiography, should be evaluated as in non-pregnant women, and anticoagulation maintained for at least 4 weeks after cardioversion.^[1]
• Longer term: beta-1-selective blockers (not atenolol) are recommended for rate control (Class I, Level C), and digoxin or verapamil should be considered if they fail or are not tolerated (Class IIa, Level C); flecainide in addition to beta-blockers should be considered for long-term rhythm control (Class IIa, Level C), and sotalol may be considered for rhythm management, controlling for pro-arrhythmic risk factors as in non-pregnant women (Class IIb, Level C).^[1]

Follow-up: She remains in persistent AF at elevated thromboembolic risk. What anticoagulant?^[1]

• ESC 2025: therapeutic LMWH is recommended (Class I, Level C); DOACs are not recommended during pregnancy (Class III, Level C), and in AF the presence of a mechanical valve or moderate to severe mitral stenosis requires a VKA.^[1]
• ESC 2024 AF, published earlier, had said VKAs should be avoided in the first trimester and from week 36.^[6]

Branch E — Drugs and lactation

Examiner: She takes a statin for familial hypercholesterolaemia and wants to conceive. What do the guidelines say?^[1]

Strong answer:

• ESC 2025 text: continuing statins may be considered during pregnancy in women with familial hypercholesterolaemia or established ASCVD; its row says continuation may be considered in established ASCVD (Class IIb, Level C).^[1]
• ACC/AHA 2026: in pregnant individuals with FH or a history of clinical ASCVD, it may be reasonable to continue statin therapy after an individualized benefit-risk discussion (COR 2b, LOE C-LD), and a hydrophilic statin such as pravastatin should be considered if continuing.^[11]
• ACC/AHA 2026 also says persons with hypercholesterolemia who are not at high risk for ASCVD and plan pregnancy should stop statin therapy 1 to 2 months before attempting to become pregnant or as soon as pregnancy is discovered, to avoid uncertain risks to the fetus (COR 1, LOE C-LD), and that bile acid sequestrants are reasonable in pregnant or lactating individuals with hypercholesterolemia without hypertriglyceridemia (COR 2a, LOE C-EO); its other rows concern HoFH and severe hypertriglyceridemia.^[11]
• Statins remain contraindicated during lactation (ESC 2025).^[1]

Follow-up: And a woman with HFrEF on an ACE inhibitor, MRA and SGLT2 inhibitor?^[3]

• ESC 2026 HF: ACE inhibitors, ARBs, ARNIs, MRAs, ivabradine and SGLT2 inhibitors are not recommended during pregnancy because of the risk of foetotoxicity or teratogenicity (Class III, Level C).^[3]
• ESC 2026 HF recommends pre-conception care and counselling for patients with HF, to facilitate decision-making surrounding HF treatments, pregnancy, contraception, pre-implantation genetic screening and assisted reproductive therapies (Class I, Level C), and ESC 2025 recommends advising women with HFrEF about the risk of deterioration of cardiac function during pregnancy and peripartum (Class I, Level C).^[3][1]
• ESC 2025: modify the drug regimen before pregnancy as part of risk stratification, with reassessment after at least 3 months.^[1]
• If she becomes pregnant with an intracardiac thrombus or EF below 35%, therapeutic-dose LMWH is recommended (ESC 2025, Class I, Level C).^[1]
• After delivery, ESC 2025 recommends optimising HF guideline-directed medical therapy, taking drugs contraindicated during lactation into account (Class I, Level C); its rows on avoiding or preventing lactation apply only in severe HF.^[1]
• In pregnant women with HFrEF, switching non-selective beta-blockers to beta-1-selective blockers (metoprolol, bisoprolol) with close mother and foetus monitoring is recommended, to reduce the risk of adverse foetal events and a lower birth weight (ESC 2026 HF, Class I, Level C).^[3]