Perinatal heart failure: AHA urges earlier recognition, more precise drug selection

Clinical takeaway: Maintain a low threshold to evaluate dyspnea or edema in pregnancy/postpartum, use natriuretic peptides and echo early, continue pregnancy-safe GDMT (β‑blockers, diuretics, hydralazine/nitrates), and avoid ACE inhibitors/ARNIs/SGLT2 inhibitors until postpartum.

Heart failure (HF) during pregnancy and up to 12 months postpartum remains underrecognized and high risk, with maternal mortality markedly increased and many cases potentially preventable. This new American Heart Association scientific statement emphasizes standardized definitions, earlier recognition, and tailored therapy for HF with reduced or mildly reduced ejection fraction (LVEF <50%) across the perinatal continuum.

“Delays in the recognition and diagnosis of heart failure during the perinatal period contribute to adverse maternal outcomes,” the authors note, underscoring the urgency of improved screening and timely treatment.

Symptoms such as dyspnea, fatigue, and edema frequently overlap with normal pregnancy, limiting reliance on clinical presentation alone. The statement encourages integration of objective testing—including natriuretic peptides (with high negative predictive value) and echocardiography—to confirm or exclude HF.

Key management recommendations and drug considerations

Pharmacotherapy should be adapted to balance maternal benefit and fetal safety:

• Preferred/acceptable during pregnancy: β-blockers (metoprolol preferred), loop diuretics for congestion, and vasodilators (hydralazine and nitrates) should be continued or initiated as needed.
• Avoid during pregnancy: ACE inhibitors, ARBs, ARNIs, mineralocorticoid receptor antagonists, and SGLT2 inhibitors should be discontinued because of fetal risk.
• Anticoagulation: Consider in severe LV dysfunction (eg, LVEF <30%), especially early postpartum.
• Breastfeeding considerations: Some agents (eg, enalapril, metoprolol) are compatible with lactation, facilitating GDMT reinitiation postpartum.

Acute HF management mirrors standard care—diuresis, afterload reduction, and stabilization—while ensuring uteroplacental perfusion and multidisciplinary coordination.

Screening, risk, and postpartum care

• Use structured tools like the CMQCC cardiovascular risk algorithm to identify high-risk patients and trigger testing.
• Recognize that most preventable cardiomyopathy-related deaths occur 7 days to 12 months postpartum, making extended follow-up essential.
• Schedule early and frequent postpartum follow-up visits and consider remote monitoring to detect decompensation.

The statement also stresses preconception counseling, multidisciplinary cardio-obstetric care, and addressing disparities—particularly among Black and Native American women, who experience higher rates of peripartum cardiomyopathy and worse outcomes.

Bottom line: Perinatal HF is common, often missed, and frequently preventable. Early testing, pregnancy-adapted GDMT, and vigilant postpartum surveillance are critical to improving maternal outcomes.

Source: Adedinsewo DA, et al. 2026 June 24. Circulation. Heart Failure Occurring in the Perinatal Period: A Scientific Statement From the American Heart Association