European Heart Journal Advance Access originally published online on August 20, 2007
European Heart Journal 2007 28(19):2419-2420; doi:10.1093/eurheartj/ehm335
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Management of pregnant women with artificial heart valves: inconsistency in ESC publications: reply
Medicinsk-kardiologisk afdeling A
Århus Sygehus
Tage-Hansens Gade 2
8000 Århus C
Denmark
Professor of Cardiology
Director of Uppsala Clinical Research Center
University Hospital
S751 85 Uppsala
Sweden
Chair of Cardiology
"G. d'Annunzio" University - Chieti
Ospedale San Camillo de Lellis
Via C. Forlanini, 50
66100 Chieti
Italy
E-mail address: rdecater{at}ifc.cnr.it; rdecater{at}unich.it
Referring to our position paper on ‘anticoagulants in heart disease: current status and perspectives’,1 Dr Mischke has noticed that the recommendations about the management of pregnant women with artificial heart valves in our position paper adhere more to the ACC/AHA than to the latest ESC guidelines on valvular heart disease.
This is indeed a quite controversial subject. No doubt pregnant women with prosthetic heart valves require anticoagulation. There is still, however, insufficient clinical evidence to make definitive recommendations about optimal antithrombotic therapy with a low risk of embryopathy, a low risk of maternal valve thrombosis, and an acceptable bleeding risk. The available evidence is discussed in detail and recommendations are given in the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy.2 The latest ACC/AHA guidelines3 closely adhere to this important and world-wide accepted paper written by experts in anticoagulation and pregnancy-related thrombo-embolism. In the ACC/AHA guidelines, it is stressed that the different options should be carefully discussed with the patient before any final decision about treatment strategy is taken. Independent of the strategy, the need for frequent monitoring is strongly emphasized.
In our position paper, we carefully evaluated the studies available on anticoagulants and pregnancy, and we did (and do) agree with the statements of the ACCP document and more recent consequent documents with the same recommendations, in that:
- the handling of anticoagulant therapy in pregnant women with prosthetic heart valves is controversial and should be managed by specialists;
- vitamin K antagonists (VKAs) should be avoided between weeks 6 and 12 and from the middle of the third trimester until delivery;
- treatments with unfractionated heparin or low-molecular-weight heparin throughout pregnancy are optional, but need to be monitored very closely by measurement of relevant coagulation parameters;
- the different treatment strategies, with all consequent risks and benefits, should be carefully discussed with any pregnant woman before any final decision of therapeutic strategy is taken.
5 mg/day) also in the first trimester of pregnancy, but this recommendation is based on data from studies of small cohorts of patients. The consensus among our panel of anticoagulation experts did not favour this view on the basis that information about the safety of VKAs even at these low doses in the first trimester of pregnancy is scarce and because we weighted the risk of embryopathy higher than the risk of thrombosis associated with alternative available treatments. Our preferred treatment strategies are reported in a table in our position paper. Dr Mischke is, however, right when he argues that we should have discussed this in more detail in our document, in order to make clear that the recommendations given were at variance from those contained in the ESC guidelines on ‘valvular heart disease’. Although there is no a priori reason to pursue consistency in different documents published by different bodies of the same professional society (the ESC in our case) at different times at all possible occasions when variable considerations of underlying values and preferences are given, we do hope that the present discussion helps clarifying the background for the inconsistency noted.
References
- De Caterina R, Husted S, Wallentin L, Agnelli G, Bachmann F, Baigent C, Jespersen J, Kristensen SD, Montalescot G, Siegbahn A, Verheugt FW, Weitz J. Anticoagulants in heart disease: current status and perspectives. Eur Heart J (2007) 28:880–913.
[Free Full Text] - Bates SM, Greer IA, Hirsh J, Ginsberg JS. Use of antithrombotic agents during pregnancy. Chest (2004) 126:627S–644S.[CrossRef][Web of Science][Medline]
- Bonow RO, Carabello BA, Kanu C, de Leon AC Jr., Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O'Gara PT, O'Rourke RA, Otto CM, Shah PM, Shanewise JS, Smith SC Jr., Jacobs AK, Adams CD, Anderson JL, Antman EM, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Lytle BW, Nishimura R, Page RL, Riegel B. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): developed in collaboration with Society of Cardiovascular Anesthesiologists: endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. Circulation (2006) 114:e81–e231.
- Vahanian A, Baumgartner H, Bax J, Butchart E, Dion R, Filippatos G, Flachskampf F, Hall R, Iung B, Kasprzak J, Nataf P, Tornos P, Torracca L, Wenink A. Guidelines on the management of valvular heart disease: The Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology. Eur Heart J (2007) 28:230–268.
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