Cardiovascular disease (>25%) is the leading cause of death among pregnant women in the United States. This chapter covers risk stratification, pathophysiology, and anesthetic management of women with specific cardiac diseases. In the last decade, advances in treatment and management of cardiac disease in the pregnant patient have led to improvements in survival of obstetric patients with known cardiac disease. Key to the improvements in care is the creation of Pregnancy Heart Teams, multidisciplinary teams with knowledge and experience caring for the obstetric patient with cardiovascular disease. Cardiovascular disease encompasses a heterogeneous group of lesions with differing hemodynamic goals, management and risks during pregnancy, delivery, and postpartum. The anesthesiologist is best able to care for these women by understanding the specific cardiovascular lesion, a woman’s current status, the obstetric and fetal considerations and the impact of anesthetic techniques.

Acute pulmonary embolism (PE) carries a high risk of morbidity and mortality and has a wide spectrum of severity, from incidental diagnosis in an asymptomatic patient to sudden refractory shock and cardiovascular collapse. Although the exact incidence remains uncertain, it is estimated that approximately 600,000 patients are diagnosed with PE annually in the United States, with mortality rates as high as 30% for patients with hemodynamic instability at presentation. A high-risk PE is one associated with hypotension or bradycardia. An intermediate-risk PE has evidence of RV strain, either by imaging or biomarkers (troponin or BNP). All others are low-risk PEs. The diagnosis of PE is often complicated by presentations that can be subtle, atypical or confounded by another coexisting disease.

Lumbar puncture (LP) is a diagnostic procedure that can be performed successfully in most patients with minimal discomfort. The key factors to a successful LP are an understanding of the anatomy of the lumbar spine, careful positioning of the patient, and a thorough palpation of the bony landmarks to identify the lumbar interspaces.

Intracerebral haemorrhage and subarachnoid haemorrhage are associated with considerable morbidity and mortality. Too often the focus is on acute treatment after a haemorrhage has occurred, instead of primary and secondary prevention. Medical therapies to control hypertension, achieve tobacco abstinence, and avoid excessive alcohol consumption can confer broad reductions in haemorrhage risk across pathophysiological subtypes. Judicious restriction of antiplatelet and anticoagulant therapies to only those individuals and those intensities for which they are indicated also can substantially reduce haemorrhagic stroke frequency. Specific endovascular and surgical therapies, judiciously employed, will further reduce risk of first or recurrent haemorrhage from structural vascular anomalies, including arteriovenous malformation, cavernous malformations, and saccular aneurysms. For unruptured intracranial aneurysms, features that favour consideration of preventive occlusion include include younger patient age, prior subarachnoid haemorrhage from a different aneurysm, familial intracranial aneurysms, large aneurysm size, irregular shape, basilar or vertebral artery location, and aneurysm growth on serial imaging. Among individuals who are technical candidates for either coiling or clipping, endovascular coiling is associated with a reduction in procedural morbidity and mortality but has a higher risk of recurrence.

Long-term (>1 year) single antiplatelet therapy with aspirin is effective in reducing the risk of any early recurrent stroke by about one-sixth compared with no antiplatelet therapy. Clopidogrel monotherapy is marginally but significantly more effective than aspirin in reducing major vascular events. Cilostazol is also more effective than aspirin in Asian patients, and its therapeutic efficacy may be augmented by the addition of probucol in patients with ischaemic stroke and high risk of cerebral haemorrhage. The safety and effectiveness of cilostazol in non-Asian patients is not known. Prasugrel monotherapy (3.75 mg daily) is not non-inferior to clopidogrel monotherapy among Japanese patients with non-cardioembolic ischaemic stroke. Dual antiplatelet therapy with aspirin and extended-release dipyridamole is more effective than aspirin monotherapy and equally effective as clopidogrel monotherapy in preventing recurrent stroke. Dual antiplatelet therapy with aspirin and clopidogrel is more effective than aspirin monotherapy in preventing recurrent ischaemic stroke and myocardial infarction in high vascular risk patients, but it also increases the risk of major bleeding which may offset its benefits. Dual antiplatelet therapy with cilostazol added to aspirin or clopidogrel is more effective, and as safe as, aspirin or clopidogrel monotherapy in Japanese patients with non-cardioembolic ischaemic stroke.

Cervical artery dissection (CAD) is characterized by an intramural haematoma due to a subintimal tear and accounts for up to 25% of ischaemic strokes in young and middle-aged adults. Data regarding intravenous thrombolysis and endovascular thrombectomy in CAD are scarce and observational – both are reasonably safe and probably recommended. Based on observational evidence, antithrombotic therapy is used to prevent first or recurrent cerebral ischaaemic events in acute or subacute CAD, and event rates are low with either antiplatelet or anticoagulant therapy. The long-term rate of recurrent cerebral ischaemic events or bleeding complications in CAD patients is small while under antithrombotic treatment. Cerebral vasculitis treatment is based on observational series. When primary angiitis of the central nervous system is confirmed by biopsy, a combination of glucocorticoids and cyclophosphamide should be started. Rituximab may be used in patients who are intolerant of cyclophosphamide. In atypical, non-biopsy-proven cases, treatment should be adapted to the severity of neurological involvement. For giant cell arteritis, initial high-dose prednisolone is recommended, beginning a slow taper after 2–4 weeks and continuing at a low dose for 1–2 years. Treatment of p-ANCA-positive and -negative systemic vasculitis with cerebral involvement includes induction corticosteroid therapy followed by addition of cyclophosphamide or other glucocorticoid-sparing drugs.

Cardiogenic embolism is a common cause of recurrent ischaemic stroke. The cardiac source of embolism is usually the left atrial appendage and atrium due to atrial fibrillation (AF). Other sources include the left ventricle, heart valves and venous system or right atrium, via a patent foramen ovale.The most effective thromboprophylactic is oral anticoagulation, which reduces the risk of recurrent stroke by about two thirds, compared to no anticoagulation. Four target-specific, direct-acting non-vitamin K antagonist oral anticoagulants (NOACs) – the direct thrombin inhibitor dabigatran etexilate, and the factor Xa inhibitors rivaroxaban, apixaban and edoxaban – are at least as efficacious and safe as warfarin, and apixaban is superior to, and as safe as, aspirin, for preventing stroke among patients with AF. Other potential stroke prevention strategies include left atrial appendage occlusion for patients with AF in whom anticoagulation is contraindicated, anticoagulation for left ventricular thrombus and prosthetic heart valves, antibiotics +/– valve surgery for infective endocarditis, and transcatheter device closure of a symptomatic patent foramen ovale.

Warfarin is highly effective in killing rats, and in the hands of the uneducated, is just as effective in killing humans. The author provides tips for getting it right every time, including how to initiate treatment, how to reverse its effects, and drug and food interactions to watch out for.

Pulmonary embolism (PE) is a potentially life-threatening condition. The management of low, intermediate and high-risk PE are explained in a stepwise fashion. Readers are provided with information on thrombolysis, and how to anticoagulate following this intervention.

Successful anticoagulation is a fine balance between clotting and bleeding, which can easily go wrong. The good news is that basic principles can help manage this scenario effectively. The author provides background information on low molecular weight heparins, their use in the treatment and prevention of deep vein thrombosis and pulmonary embolism, its monitoring and reversal, and dose adjustment for body weight and renal function.