European Heart Journal Advance Access originally published online on April 25, 2007
European Heart Journal 2007 28(10):1267; doi:10.1093/eurheartj/ehm094
Guidelines on the management of valvular heart disease
Department of Cardiology
Puerta de Hierro Hospital
C/San Martin Porres 4
Madrid 28035
Spain
Department of Cardiology
Puerta de Hierro Hospital
C/San Martin Porres 4
Madrid 28035
Spain
Department of Cardiology
Puerta de Hierro Hospital
C/San Martin Porres 4
Madrid 28035
Spain
Tel: 34649283903; fax: 34649283903. E-mail address: aguiarsouto{at}hotmail.com
We have read with interest the recently published European guidelines on management valvular heart disease.1
Our attention was focussed on the section dealing with the management during pregnancy. In table 18 where general recommendations are listed, the medical therapy is favoured in most patients with regurgitant valve disease, even in symptomatic patients with a high level of evidence (IC). As it is reported beside, vasodilators should be used carefully especially in the case of angiotensin-converting-enzyme (ACE) inhibitors and angiotensin receptor blockers.
Under the ‘management strategy’ section, patients with symptomatic aortic/mitral regurgitation during pregnancy are treated medically using diuretics at the lowest dose possible to avoid impairing foetal perfusion and vasodilators.
In our point of view, guidelines should explain clearly the well-known increased risk of fetopathy related to the use of ACE-inhibitors not only during the second and third trimesters of pregnancy but also during the first trimester. When they are used in the second half of pregnancy, they can cause oligohydramnios, fetal growth retardation, pulmonary hypoplasia, joint contractures, hypocalvaria and neonatal renal failure, hypotension, and death.2–4 Infants with first-trimester exposure to ACE-inhibitors had an increased risk of major (cardiovascular and the central nervous system) congenital malformations.5
Because of its important clinical relevance, the use of ACE-inhibitors should be clearly avoided during pregnancy and guidelines should exposure this fact so.
References
- Vahanian A. Guidelines on the management of valvular heart disease. Eur Heart J (2007) 28:230–268.
[Free Full Text] - Quan A. Fetopathy associated with exposure to angiotensin converting enzyme inhibitors and angiotension receptor antagonists. Early Hum Dev (2006) 82:23–28.[CrossRef][Web of Science][Medline]
- Buttar HS. An overview of the influence of ACE inhibitors on fetal-placental circulation and perinatal development. Mol Cell Biochem (1997) 176:61–71.[CrossRef][Web of Science][Medline]
- Barr M Jr. Teratogen update: angiotensin-converting enzyme inhibitors. Teratology (1994) 50:399–409.[CrossRef][Web of Science][Medline]
- Cooper WO. Major congenital malformations after first-trimester exposure to ACE inhibitors. N Engl J Med (2006) 354:2443–2451.
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