Frequency of peripartum cardiomyopathy

Genome-wide significance and replication of the chromosome 12p11.22 locus near the PTHLH gene for peripartum cardiomyopathy

BACKGROUND

Peripartum (PP) cardiomyopathy (CM) is a rare condition of unknown etiology that occurs in late pregnancy or early postpartum. Initial evidence suggests that genetic factors may influence PPCM. This study evaluated and replicated genome-wide association of single nucleotide polymorphisms with PPCM.

METHODS AND RESULTS

Genome-wide single nucleotide polymorphisms in women with verified PPCM diagnosis (n=41) were compared separately with local control subjects (n=49 postmenopausal age-discordant women with parity ≥1 and no heart failure) and iControls (n=654 women ages 30 to 84 years with unknown phenotypes). A replication study of independent population samples used new cases (PPCM2, n=30) compared with new age-discordant control subjects (local2, n=124) and with younger control subjects (n=89) and obstetric control subjects (n=90). A third case set of pregnancy-associated CM cases not meeting strict PPCM definitions (n=29) was also studied. In the genome-wide association study, 1 single nucleotide polymorphism (rs258415) met genome-wide significance for PPCM versus local control subjects (P=2.06×10(-8); odds ratio [OR], 5.96). This was verified versus iControls (P=7.92×10(-19); OR, 8.52). In the replication study for PPCM2 cases, rs258415 (ORs are per C allele) replicated at P=0.009 versus local2 control subjects (OR, 2.26). This replication was verified for PPCM2 versus younger control subjects (P=0.029; OR, 2.15) and versus obstetric control subjects (P=0.013; OR, 2.44). In pregnancy-associated cardiomyopathy cases, rs258415 had a similar effect versus local2 control subjects (P=0.06; OR, 1.79), younger control subjects (P=0.14; OR, 1.65), and obstetric control subjects (P=0.038; OR, 1.99).

CONCLUSIONS

Genome-wide association with PPCM was discovered and replicated for rs258415 at chromosome 12p11.22 near PTHLH. This study indicates a role of genetic factors in PPCM and provides a new locus for further pathophysiological and clinical investigation.

Peripartum cardiomyopathy

Peripartum cardiomyopathy (PPCM) is a potentially devastating disease that affects women during the last months of pregnancy or the first months after delivery. The aetiology and pathogenesis of this disease remain unclear, but oxidative stress and the generation of a cardiotoxic fragment of prolactin may play key roles. Diagnosing PPCM remains a challenge, as symptoms may mimic those women experience during normal pregnancy and the peripartum period. A high index of suspicion is thus necessary to make the diagnosis. Patients with PPCM have a varied clinical course, as some patients achieve full recovery while others progress to end-stage heart failure and even death. Standard heart failure treatment is indicated, although special provisions are necessary in pregnant and lactating women. Additional research into the pathophysiology of this disease, including possible genetic contributions, may lead to novel treatment strategies that can improve outcomes.

Evaluation of the clinical relevance of baseline left ventricular ejection fraction as a predictor of recovery or persistence of severe dysfunction in women in the United States with peripartum cardiomyopathy

BACKGROUND

Baseline left ventricular ejection fraction (LVEF) has been shown to be associated with likelihood of recovery in patients with peripartum cardiomyopathy (PPCM). The clinical relevance of this association for individual patients is unclear.

METHODS AND RESULTS

We analyzed baseline parameters of LVEF in 187 PPCM patients with ≥6 months follow-up data in an attempt to detect the value of baseline LVEF as a predictor of early recovery or persistence of severe LV dysfunction. Recovery of LV function (LVEF ≥50%) at 6 months after diagnosis was found in 115 patients (61%). Multivariate analysis identified baseline LVEF >30% as a significant predictor for recovery (odds ratio 5.2, 95% confidence interval 1.96-7.70; P > .0001). Recovery of LV function was 6.4-fold higher in women with baseline LVEF ≥ 30% (group III) and 3.9-fold higher in women with LVEF 20%-29% (group II) compared with those with LVEF 10%-19% (group I). Failure to achieve full recovery was seen in 63% of group I patients, 32% of group II (P = .03), and 21% of group III (P = .02 vs group I). Failure to achieve LVEF ≥30% was seen in 30% of group I patients and 13% of group II (P = .09).

CONCLUSIONS

Early recovery in patients with PPCM is significantly related to the degree of myocardial insult at time of diagnosis. Baseline LVEF however, has a limited sensitivity for prediction of failure to improve in individual patients and can not be used as an indication for premature use of aggressive therapy including devices or cardiac transplantation.

Peripartum cardiomyopathy: the need for a national database

Peripartum cardiomyopathy (PPCM) is a rare and life-threatening disease that affects young women in the last month of pregnancy or within 5 months of delivery. It is a form of dilated cardiomyopathy with left-sided systolic dysfunction. The incidence rate in the Western world is estimated to be 1:3000. Symptoms of PPCM vary greatly and may be obscured by common physiological aspects of pregnancy. Therefore, the incidence rate might be higher. Echocardiography or MRI can confirm or rule out PPCM. Unfortunately, there is no specific risk factor profile available. The clinical course varies from complete recovery to deterioration of cardiac function. Patients with PPCM, especially those whose ventricular function has not returned to normal, are advised against further pregnancy. Recently, more disease-specific therapeutic strategies have been developed with promising results for prolactin blockade by bromocriptine. Increasing awareness for PPCM among general practitioners, gynaecologists and cardiologists may help to diagnose patients efficiently in order to start adequate treatment. A national registry is warranted to identify risk factor profiles and to optimise treatment strategies.

Case report and mini literature review: anesthetic management for severe peripartum cardiomyopathy complicated with preeclampsia using sufetanil in combined spinal epidural anesthesia

Peripartum cardiomyopathy (PPCM) is a rare entity, and anesthetic management for cesarean section of a patient with this condition can be challenging. We hereby present the anesthetic management of a patient with PPCM complicated with preeclampsia scheduled for cesarean section, along with a mini review of literature. A 24 year-old primigravida with twin gestation was admitted to our hospital with severe PPCM and preeclampsia for peripartum care, which finally required a cesarean section. Preoperative optimization was done according to the goal of managing left ventricular failure. Combined spinal epidural (CSE) anaesthesia with bupivacaine and sufentanil was used for cesarean section under optimal monitoring. The surgery was completed without event or complication. Postoperative pain relief was adequate and patient required only one epidural top up with sufentanil 6 hours after operation. To the best of our knowledge there is no report in literature of the use of sufentanil as a neuraxial opioid in the anesthetic management of cesarean section in a patient with PPCM. CSE with sufentanil may be a safer and more effective alternative in such cases.

Dyspnoea at term in an obese mother

Peripartum cardiomyopathy is a serious, potentially life-threatening heart disease of uncertain aetiology in previously healthy women. We report a morbidly obese woman who presented with peripartum shortness of breath. We discuss the differential diagnosis of dyspnoea in pregnancy and highlight the complexity of care of the morbidly obese woman.

"I am not alone": a survey of women with peripartum cardiomyopathy and their participation in an online support group

Peripartum cardiomyopathy is a devastating condition in which women without a previously identified heart condition experience heart failure in the ninth month of pregnancy or in the first 5 months after delivery of a baby. Online support groups are virtual communities for people affected by the same social or health issue. No literature exists on the benefits of women involved in an online support group for peripartum cardiomyopathy. The purpose of this descriptive study was to determine the benefits of participation in the online support group for peripartum cardiomyopathy based on a survey of active members of the group. All contacts between researchers and respondents were through e-mail. A survey of open-ended and Likert-type questions was used. Twelve women, aged 19 to 34 years, participated; all had a diagnosis of peripartum cardiomyopathy. This online support group is a vital resource for women with peripartum cardiomyopathy. Benefits to participation in the online support group included getting and sharing information, exchanging stories, being understood by other women, and gaining hope. Nurse practice implications include referring patients to reputable Web sites and support groups and serving as a professional facilitator in an online group.

Interventions for treating peripartum cardiomyopathy to improve outcomes for women and babies

BACKGROUND

Peripartum cardiomyopathy (PPCM or PCMO) is a rare disease of unknown etiology, characterised by an acute onset of heart failure in women in the late stage of pregnancy or in the early months postpartum.

OBJECTIVES

To assess the effectiveness and safety of any intervention for the care of women and/or their babies with a diagnosis of peripartum cardiomyopathy.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (27 July 2010) and the reference lists of identified studies.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials of any intervention for treating peripartum cardiomyopathy. Such interventions include: drugs; cardiac monitoring and treatment; haemodynamic monitoring and treatments; supportive therapies and heart transplant.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction. Data entry was checked.

MAIN RESULTS

We identified and included one pilot study, involving 20 women, undertaken in South Africa. Women were diagnosed postnatally and included in the study within 24 hours of diagnosis.

AUTHORS' CONCLUSIONS

There are insufficient data to draw any firm conclusions. Treatment with bromocriptine appears promising, although women would be unable to breastfeed due to suppression of lactation.

The 2010 Canadian Cardiovascular Society guidelines for the diagnosis and management of heart failure update: Heart failure in ethnic minority populations, heart failure and pregnancy, disease management, and quality improvement/assurance programs

Since 2006, the Canadian Cardiovascular Society heart failure (HF) guidelines have published annual focused updates for cardiovascular care providers. The 2010 Canadian Cardiovascular Society HF guidelines update focuses on an increasing issue in the western world - HF in ethnic minorities - and in an uncommon but important setting - the pregnant patient. Additionally, due to increasing attention recently given to the assessment of how care is delivered and measured, two critically important topics - disease management programs in HF and quality assurance - have been included. Both of these topics were written from a clinical perspective. It is hoped that the present update will become a useful tool for health care providers and planners in the ongoing evolution of care for HF patients in Canada.

Asymptomatic left ventricular dysfunction in puerperal women: an echocardiographic-based study

BACKGROUND

Peripartum cardiomyopathy is a rare but significant cause of maternal morbidity and mortality. Identification of silent forms of ventricular dysfunction associated with the peripartum period is challenging, yet necessary to establish specific counseling and therapeutic measures to prevent progression to overt heart failure. Our aims were to determine the prevalence of asymptomatic left ventricular systolic dysfunction in puerperium and compare its progression with that of cases of peripartum cardiomyopathy occurring in the same study period.

METHODS

Cross-sectional study conducted from September 2002 to April 2005 to determine by echocardiography the prevalence of asymptomatic ventricular dysfunction in early puerperium and a nested cohort study from November 2007 to January 2008 to obtain clinical and echocardiography follow-up data of positively screened patients. All clinically diagnosed cases of peripartum cardiomyopathy occurring in the same study period were also examined.

RESULTS

We screened 1182 puerperal women; ten cases (0.85%) of asymptomatic ventricular dysfunction were detected characterized by either decreased left ventricular systolic function and/or increased end-diastolic diameter. Incidence of peripartum cardiomyopathy was 6 cases/10,866 deliveries (1/1811 live births) in the same period. An echocardiogram-based follow-up study performed after a mean of 4.0years (2.9-5.2years), showed significant and similar improvement in parameters of left ventricular function in both groups (p>0.05).

CONCLUSIONS

Asymptomatic left ventricular dysfunction in puerperal women shows a high prevalence and a pattern of long term echocardiographic changes similar to those found in overt peripartum cardiomyopathy.

African-American women have a higher risk for developing peripartum cardiomyopathy

OBJECTIVES

The purpose of this study was to assess whether African-American women are at increased risk of having peripartum cardiomyopathy.

BACKGROUND

Peripartum cardiomyopathy is a heart disease of unknown cause that affects young women, often with devastating consequences. The frequency of peripartum cardiomyopathy varies markedly between African and non-African regions.

METHODS

A case-control study was performed at a regional center that provides medical care to a racially heterogeneous population. For each case, 3 healthy control patients were randomly selected who delivered babies within the same month.

RESULTS

African-American women had a 15.7-fold higher relative risk of peripartum cardiomyopathy than non-African Americans (odds ratio [OR]: 15.7, 95% confidence interval [CI]: 3.5 to 70.6). Other significant univariate risk factors were hypertension (OR: 10.8, 95% CI: 2.6 to 44.4), being unmarried (OR: 4.2, 95% CI: 1.4 to 12.3), and having had >2 previous pregnancies (OR: 2.9, 95% CI: 1.1 to 7.4). African-American ethnicity remained a significant risk factor for peripartum cardiomyopathy when other risk factors were considered in multivariable (OR: 31.5, 95% CI: 3.6 to 277.6) and stratified analyses (OR: 12.9 to 29.1, p < 0.001). Although the frequency of peripartum cardiomyopathy (185 of 100,000 deliveries) at this center was higher than in previous U.S. reports, it was comparable to the frequency in countries with more women of African descent (100 to 980 of 100,000). Analysis of other U.S. studies confirmed that the frequency of peripartum cardiomyopathy was significantly higher among African-American women.

CONCLUSIONS

African-American women have significantly higher odds of having peripartum cardiomyopathy that could not be explained by several other factors. Further research will be necessary to determine the potential environmental and/or genetic factors associated with African descent that confer this risk.

Peripartum cardiomyopathy: a current review

Peripartum cardiomyopathy (PPCM) is a rare but potentially lethal complication of pregnancy occurring in approximately 1 : 3,000 live births in the United States although some series report a much higher incidence. African-American women are particularly at risk. Diagnosis requires symptoms of heart failure in the last month of pregnancy or within five months of delivery in the absence of recognized cardiac disease prior to pregnancy as well as objective evidence of left ventricular systolic dysfunction. This paper provides an updated, comprehensive review of PPCM, including emerging insights into the etiology of this disorder as well as current treatment options.

Clinical profile and predictors of complications in peripartum cardiomyopathy

BACKGROUND

Clinical profile and predictors of major adverse events (MAE) associated with peripartum cardiomyopathy (PPCM) have not been characterized.

METHODS AND RESULTS

A retrospective review and analysis of clinical data of 182 patients with PPCM. Forty-six patients had >or=1 MAE, including death (13), heart transplantation (11), temporary circulatory support (4), cardiopulmonary arrest (6), fulminant pulmonary edema (17), thromboembolic complications (4), and defibrillator or pacemaker implantation (10). Diagnosis of PPCM was delayed >or=1 week in 48% of patients with MAE that preceded the diagnosis in 50% of these patients. Seven (32%) of the surviving patients who had MAE and did not undergo heart transplantation had residual brain damage. Significant predictors of MAE were: left ventricular ejection fraction <or=25% (HR 4.20, CI 2.04-8.64) and non-Caucasian background(HR 2.16, CI 1.17- 3.97). These predictors in addition to diagnosis delay (HR 5.51, CI 1.21-25.04) were also associated with death or heart transplantation.

CONCLUSIONS

1. PPCM may be associated with mortality or severe and lasting morbidity. 2. Incidence of MAE is higher in non-Caucasians and in women with left ventricular ejection fraction <or=25%. 3. Diagnosis of PPCM is often delayed and preceded by MAE. 4. Increased awareness of PPCM is required for early diagnosis and aggressive therapy in an attempt to prevent complications.

Incidence and outcome of peripartum cardiomyopathy from a tertiary hospital in South India

There is very little literature regarding peripartum cardiomyopathy (PCM) from Asian countries. A study of PCM was conducted at Kasturba Medical College Hospital, Manipal, with special reference to incidence and outcome. The incidence of PCM was 1 case per 1374 live births. Major risk factors for the development of PCM were multiparity and advanced maternal age. Echocardiography is useful in early diagnosis and for follow-up assessment of left ventricular function. Most of the patients noticed good symptomatic improvement at time of discharge and during the follow-up with standard therapy. Clinical improvement was well correlated with improvement of LV function by echocardiography. Significant thrombotic complications were noticed. None of the patients died during the study and follow-up period.

Emergency management of decompensated peripartum cardiomyopathy

Peripartum cardiomyopathy (PPCM) is a rare life-threatening cardiomyopathy of unknown cause that occurs in the peripartum period in previously healthy women.[1] the symptomatic patients should receive standard therapy for heart failure, managed by a multidisciplinary team. The diagnosis of PPCM rests on the echocardiographic identification of new left ventricular systolic dysfunction during a limited period surrounding parturition. Diagnostic criteria include an ejection fraction of less than 45%, fractional shortening of less than 30%, or both, and end-diastolic dimension of greater than 2.7 cm/m(2) body surface-area. This entity presents a diagnostic challenge because many women in the last month of a normal pregnancy experience dyspnea, fatigue, and pedal edema, symptoms identical to early congestive heart failure. There are no specific criteria for differentiating subtle symptoms of heart failure from normal late pregnancy. Therefore, it is important that a high index of suspicion be maintained to identify the rare case of PPCM as general examination showing symptoms of heart failure with pulmonary edema. PPCM remains a diagnosis of exclusion. No additional specific criteria have been identified to allow distinction between a peripartum patient with new onset heart failure and left ventricular systolic dysfunction as PPCM and another form of dilated cardiomyopathy. Therefore, all other causes of dilated cardiomyopathy with heart failure must be systematically excluded before accepting the designation of PPCM. Recent observations from Haiti[2] suggest that a latent form of PPCM without clinical symptoms might exist. The investigators identified four clinically normal postpartum women with asymptomatic systolic dysfunction on echocardiography, who subsequently either developed clinically detectable dilated cardiomyopathy or improved and completely recovered heart function.

Reviewing peripartum cardiomyopathy: current state of knowledge

Peripartum cardiomyopathy (PPCM) is a serious, potentially life-threatening heart disease of unknown etiology in previously healthy women that develops between the last month of pregnancy and 5–6 months after delivery. PPCM is a distinct clinical entity in which echocardiography demonstrates the features of an idiopathic dilated cardiomyopathy with a high morbidity and mortality, but in addition, patients suffering with PPCM have a chance of reaching full recovery. A variety of potential risk factors related to PPCM have been suggested over the last decades, which may help to identify women at risk in the future. Recent advances in understanding the pathophysiology of PPCM assign a key role to unbalanced oxidative stress and the generation of a cardiotoxic prolactin subfragment. In this regard, pharmacological blockade of prolactin holds the promise of novel, more disease-specific therapy options. The present article provides an overview on the clinical appearance and management, risk factors and potential pathophysiological mechanisms of PPCM.

Aetiology and risk factors of peripartum cardiomyopathy: a systematic review

BACKGROUND

Peripartum cardiomyopathy (PPCM) is a disorder of unknown aetiology in which heart failure due to left ventricular dysfunction occurs between the last month of pregnancy and first five months post-partum. Theories abound concerning the specific cause and risk factors for PPCM, but none have been accepted universally. The primary objective of this review was to summarize the state of knowledge on the pathogenesis of PPCM, especially in light of recent studies.

METHODS

We searched MEDLINE (January 1966-September 2007), OVID, and reference lists of articles for studies containing information on the aetiology and risk factors for PPCM, and published in English.

RESULTS

The literature reveals a wealth of articles proposing various mechanisms for aetiology and risk factors of PPCM. There is conflicting evidence on the pathogenetic role of viral myocarditis, abnormal immune response to pregnancy, abnormal response to the haemodynamic stress of pregnancy, accelerated myocyte apoptosis, cytokine-induced inflammation, malnutrition, genetic factors, excessive prolactin production, abnormal hormonal function, increased adrenergic tone, and myocardial ischaemia. A number of factors are postulated to increase the risk of the development of PPCM. These include non-Caucasian ethnicity, advanced maternal age, multiparity, poor socioeconomic status, multiple pregnancy and prolonged tocolytic use. The authors call for a strict definition of PPCM that excludes known causes of heart failure, such as the pregnancy-induced hypertensive spectrum of disorders.

CONCLUSION

The aetiology and risk factors for PPCM are poorly defined. There is a need for large-scale multi-centre epidemiological studies and registries to delineate the aetiology and pathogenesis of PPCM.

Incidence, mortality, and racial differences in peripartum cardiomyopathy

There are no large population-based studies on the incidence and prognosis of peripartum cardiomyopathy (PC). Between 1996 and 2005, there were 241,497 deliveries within the Southern California Kaiser healthcare system. Among these, we identified 60 cases of PC by searching for an International Classification of Diseases, Ninth Edition diagnosis of heart failure (HF) and detailed chart review. PC was confirmed if all of the following criteria were satisfied: (1) left ventricular ejection fraction <0.50, (2) met the Framingham criteria for HF, (3) new symptoms of HF or initial echocardiographic diagnosis of left ventricular dysfunction occurred in the month before or in the 5 months after delivery, and (4) no alternative cause of HF could be identified. The overall incidence of PC was 1 in 4,025 deliveries. The incidence in whites, African-Americans, Hispanics, and Asians was 1 of 4,075, 1 of 1,421, 1 of 9,861, and 1 of 2,675 deliveries, respectively. The incidence of PC was greatest in African-Americans, which was 2.9-fold higher compared with whites (p = 0.03) and 7-fold that of Hispanics (p <0.001). With a mean follow-up of 4.7 years, the freedom from all-cause death was 96.7% by the Kaplan-Meier method. In conclusion, this large population-based study highlights important racial differences in the incidence of PC. We observed the lowest incidence of PC in Hispanics and the highest in African-Americans. Our findings also suggest that the current mortality associated with PC may be less than reported in older series, perhaps because of the high utilization of modern HF therapy.

Peripartum cardiomyopathy

Peripartum cardiomyopathy (PPCM) is a disorder in which initial left ventricular systolic dysfunction and symptoms of heart failure occur between the late stages of pregnancy and the early postpartum period. It is common in some countries and rare in others. The causes and pathogenesis are poorly understood. Molecular markers of an inflammatory process are found in most patients. Clinical presentation includes usual signs and symptoms of heart failure, and unusual presentations relating to thromboembolism. Clinicians should consider PPCM in any peripartum patient with unexplained disease. Conventional heart failure treatment includes use of diuretics, beta blockers, and angiotensin-converting enzyme inhibitors. Effective treatment reduces mortality rates and increases the number of women who fully recover left ventricular systolic function. Outcomes for subsequent pregnancy after PPCM are better in women who have first fully recovered heart function. Areas for future research include immune system dysfunction, the role of viruses, non-conventional treatments such as immunosuppression, immunoadsorption, apheresis, antiviral treatment, suppression of proinflammatory cytokines, and strategies for control and prevention.