Incidence, mortality, and racial differences in peripartum cardiomyopathy

[Peripartum cardiomyopathy: a rare, unknown and potentially fatal disease]

Peripartum cardiomyopathy occurs in women with no prior history of cardiac dysfunction, and is presented by left heart failure. It occurs late in pregnancy or in the months after delivery. Rare in Europe, it is not well-known by obstetricians. The prognosis can be good with restitutio in integrum of the maternal cardiac function but the outcome can be dramatic and lead to death of the patient as the case in this report.

The relationship between pre-eclampsia and peripartum cardiomyopathy: a systematic review and meta-analysis

OBJECTIVES

The goal of this study was to systematically review the peripartum cardiomyopathy (PPCM) literature and determine the prevalence of pre-eclampsia (PE) in women with PPCM. Secondary analyses included evaluation of the prevalence of hypertensive disorders, multiple gestations, and multiparity.

BACKGROUND

PPCM is a significant cause of maternal and infant morbidity and mortality worldwide, yet its etiology remains unknown. PE is often cited as a risk factor for the development of PPCM and recent research suggests that PE and PPCM share mechanisms that contribute to their pathobiology. No comprehensive evaluation of the relationship between PE and PPCM exists.

METHODS

A systematic predetermined search strategy was performed in multiple databases to identify studies describing ≥3 women with PPCM. Prevalence rates of PE, hypertension, multiple gestations, and multiparity were pooled.

RESULTS

Data from 22 studies (n = 979) were included in this analysis. The pooled prevalence of 22% (95% confidence interval [CI]: 16% to 28%) was more than quadruple the 5% average worldwide background rate of PE in pregnancy (p < 0.001). There were no geographic or racial differences detected in the prevalence of PE in women with PPCM. The rates of hypertension during pregnancy (37% [95% CI: 29% to 45%]) and multiple gestations (9% [95% CI: 7% to 11%]) were also elevated.

CONCLUSIONS

The prevalence of PE, hypertensive disorders, and multiple gestations in women with PPCM is markedly higher than that in the general population. These findings support the concept of a shared pathogenesis between PE and PPCM and highlight the need for awareness of the overlap between these 2 diseases.

Peripartum cardiomyopathy: a contemporary review

Peripartum cardiomyopathy is a rare and potentially fatal disease. Though approximately half of the patients recover, the clinical course is highly variable and some patients develop refractory heart failure and persistent left ventricular systolic dysfunction. It is diagnosed when women present with heart failure secondary to left ventricular systolic dysfunction towards the end of pregnancy or in the months following delivery, where no other cause of heart failure is found. Etiology remains unclear, and treatment is similar to other cardiomyopathies and includes evidence-based standard heart failure management strategies. Experimental strategies such as intravenous immunoglobulin and bromocriptine await further clinical validation.

Peripartum cardiomyopathy

Peripartum cardiomyopathy (PPCM) is a rare form of unexplained cardiac failure of unknown origin, unique to the pregnant woman with highly variable outcome associated with high morbidity and mortality. PPCM is fraught with controversies in its definition, epidemiology, pathophysiology, diagnosis and management. PPCM is frequently under diagnosed, inadequately treated and without a laid down follow-up regimen, thus, the aim of this review. Publications on PPCM were accessed using Medline, Google scholar and Pubmed databases. Relevant materials on PPCM, selected references from internet services, journals, textbooks, and lecture notes on PPCM were also accessed and critically reviewed. PPCM is multifactorial in origin. It is a diagnosis of exclusion and should be based on classic echocardiographic criteria. The outcome of PPCM is also highly variable with high morbidity and mortality rates. Future pregnancies are not recommended in women with persistent ventricular dysfunction because the heart cannot tolerate increased cardiovascular workload associated with the pregnancy. Although, multiparity is associated with PPCM, there is an increased risk of fetal prematurity and fetal loss. PPCM is a rare form of dilated cardiomyopathy of unknown origin, unique to pregnant women. The pathophysiology is poorly understood. Echocardiography is central to diagnosis of PPCM and effective treatment monitoring in patients of PPCM. The outcome is highly variable and related to reversal of ventricular dysfunction.

Detection of peripartum myocardial burden by vector-projected 187 channel electrocardiography and serum NT-proBNP

There is no reliable method of screening for pregnant women at high risk of developing severe myocardial disorders. In this study, we used vector-projected 187 channel electrocardiography (DREAM-ECG) and serum biochemical markers to evaluate peripartum myocardial burden in pregnant women. Forty-one pregnant women were examined at 36-37 weeks gestation (GW36), 7 days postpartum (PPD7), and 1 month postpartum (PPM1). Ten non-pregnant control women were assessed at a single time point. Heart rate, sympathetic index, and repolarization index (RTc dispersion) were quantified using the DREAM-ECG system, and serum levels of NT-proBNP, cardiac troponin T, estrogen, and progesterone were determined. Heart rate and the sympathetic index decreased from GW36 to PPM1 (P = 0.0031). The repolarization index decreased over time and was greater than in non-pregnant controls (31 ± 13 ms). Estrogen and progesterone at PPD7 and PPM1 were significantly lower than those at GW36 (P < 0.0001, P < 0.001). NT-proBNP at PPD7 was greater than at GW36 (median 29 pg/mL at GW36, 86 pg/mL at PPD7), and decreased at PPM1 in comparison to PPD7 (median 18.5 pg/mL). Troponin T was in the normal range during the whole period (< 0.003 ng/mL). In conclusion, these results indicate that the peripartum myocardial burden in pregnant women does not return to normal nonpregnant levels by PPM1. We propose that both repolarization indexes such as RTc dispersion by DREAM-ECG and serum biochemical markers may identify pregnant women at high risk of developing severe myocardial damage in the peripartum period.

Heart failure in sub-Saharan Africa

The heart failure syndrome has been recognized as a significant contributor to cardiovascular disease burden in sub-Saharan African for many decades. Seminal knowledge regarding heart failure in the region came from case reports and case series of the early 20th century which identified infectious, nutritional and idiopathic causes as the most common. With increasing urbanization, changes in lifestyle habits, and ageing of the population, the spectrum of causes of HF has also expanded resulting in a significant burden of both communicable and non-communicable etiologies. Heart failure in sub-Saharan Africa is notable for the range of etiologies that concurrently exist as well as the healthcare environment marked by limited resources, weak national healthcare systems and a paucity of national level data on disease trends. With the recent publication of the first and largest multinational prospective registry of acute heart failure in sub-Saharan Africa, it is timely to review the state of knowledge to date and describe the myriad forms of heart failure in the region. This review discusses several forms of heart failure that are common in sub-Saharan Africa (e.g., rheumatic heart disease, hypertensive heart disease, pericardial disease, various dilated cardiomyopathies, HIV cardiomyopathy, hypertrophic cardiomyopathy, endomyocardial fibrosis, ischemic heart disease, cor pulmonale) and presents each form with regard to epidemiology, natural history, clinical characteristics, diagnostic considerations and therapies. Areas and approaches to fill the remaining gaps in knowledge are also offered herein highlighting the need for research that is driven by regional disease burden and needs.

Article Commentary: Acute Heart Failure: Is it Peripartum Cardiomyopathy or Not?

Peripartum cardiomyopathy (PPCM) is a potentially life-threatening disease that occurs in women of childbearing age.

Peripartum cardiomyopathy: a review

Peripartum cardiomyopathy (PPCM) is a form of dilated cardiomyopathy of unclear etiology affecting women without preexisting heart disease during the last month of pregnancy or during the first 5 months postpartum. Its incidence shows marked geographic and ethnic variation, being most common in Africa and among women of African descent. Most women present in the first month postpartum with typical heart failure symptoms such as dyspnea, lower extremity edema, and fatigue. These symptoms are often initially erroneously diagnosed as part of the normal puerperal process. Diagnosis can be aided by the finding of a significantly elevated serum brain natriuretic peptide. The etiology of PPCM is unclear; however, recent research suggests abnormal prolactin metabolism is seminal in its development, and prolactin antagonism with bromocriptine shows promise as a novel treatment for PPCM.

16-kDa prolactin and bromocriptine in postpartum cardiomyopathy

Peripartum cardiomyopathy (PPCM) is a potentially life-threatening heart disease emerging toward the end of pregnancy or in the first postpartal months in previously healthy women. Recent data suggest a central role of unbalanced peri-/postpartum oxidative stress that triggers the proteolytic cleavage of the nursing hormone prolactin (PRL) into a potent antiangiogenic, proapoptotic, and proinflammatory 16-kDa PRL fragment. This notion is supported by the observation that inhibition of PRL secretion by bromocriptine, a dopamine D2-receptor agonist, prevented the onset of disease in an animal model of PPCM and by first clinical experiences where bromocriptine seem to exert positive effects with respect to prevention or treatment of PPCM patients. Here, we highlight the current state of knowledge on diagnosis of PPCM, provide insights into the biology and pathophysiology of 16-kDa PRL and bromocriptine, and outline potential consequences for the clinical management and treatment options for PPCM patients.

Natural history, management, and outcomes of peripartum cardiomyopathy: an Irish single-center cohort study

AIM

To describe the natural history, management and outcomes of peripartum cardiomyopathy (PPCM) in an unselected Northern European population.

METHODS

A retrospective single-center observational study was performed at a tertiary referral heart failure and transplantation unit. Outcomes measured were baseline demographics, clinical presentation, course, and treatment. Echocardiographic findings were compared at baseline, 2 months, and 6 months.

RESULTS

Twelve cases of PPCM were identified between 2002 and 2008. Mean age was 34.7 years. Nine patients were multiparous and nine had preeclampsia. Ten patients presented in the first week postpartum. Two patients required inotropic support. Mean ejection fraction (EF) at presentation was 27% (SD = 8%) which improved to 47% (SD = 13%) at 6 months. At this time, 10 patients were asymptomatic and 6 had recovered normal cardiac function. Left ventricular (LV) function improved but did not reach normal limits in five cases. One case with persistent severe LV dysfunction required cardiac transplantation. One patient suffered an arrhythmic death several years after the 6 months follow-up period.

CONCLUSIONS

PPCM is a rare condition. With appropriate therapy, a good clinical outcome is common but not universal. Continued deterioration requiring ventricular support and cardiac transplantation can occur. In our cohort, older maternal age, multiparity, and preeclampsia appeared to be risk factors.

Heart failure in women

Heart failure (HF) has steadily increased in prevalence and affects both males and females equally. Despite this, there has been a significant underrepresentation of women in large scale HF trials. This disparity has lead to a deficit in understanding important gender-based differences in pathophysiology, diagnosis and treatment strategies. We review these gaps and explore a biological basis for varying outcomes. Endogenous estrogen plays an important role in epidemiology and outcome. The administration of exogenous estrogen has had varied success in treatment and is outlined extensively below. Additionally, we highlight unique HF syndromes through pregnancy and important sex-specific issues concerning transplant and mechanical circulatory support. A central theme remains: there is a clear need for increased female recruitment in clinical trials, and more studies exploring the role of gender-based biology in HF treatment.

A systematic review of validated methods for identifying heart failure using administrative data

PURPOSE

To identify and describe the validity of algorithms used to detect heart failure (HF) using administrative and claims data sources.

METHODS

A systematic review of PubMed and Iowa Drug Information Service searches of the English language was performed to identify studies published between 1990 and 2010 that evaluated the validity of algorithms for the identification of patients with HF using and claims data. Abstracts and articles were reviewed by two study investigators to determine their relevance on the basis of predetermined criteria.

RESULTS

The initial search strategy identified 887 abstracts. Of these, 499 full articles were reviewed and 35 studies included data to evaluate the validity of identifying patients with HF. Positive predictive values (PPVs) were in the acceptable to high range, with most being very high (>90%). Studies that included patients with a primary hospital discharge diagnosis of International Classification of Diseases, Ninth Revision, code 428.X had the highest PPV and specificity for HF. PPVs for this algorithm ranged from 84% to 100%. This algorithm, however, may compromise sensitivity because many HF patients are managed on an outpatient basis. The most common 'gold standard' for the validation of HF was the Framingham Heart Study criteria.

CONCLUSIONS

The algorithms and definitions used to identify HF using administrative and claims data perform well, particularly when using a primary hospital discharge diagnosis. Attention should be paid to whether patients who are managed on an outpatient basis are included in the study sample. Including outpatient codes in the described algorithms would increase the sensitivity for identifying new cases of HF.

Peripartum cardiomyopathy: review and practice guidelines

Peripartum cardiomyopathy, a type of dilated cardiomyopathy of unknown origin, occurs in previously healthy women in the final month of pregnancy and up to 5 months after delivery. Although the incidence is low-less than 0.1% of pregnancies -morbidity and mortality rates are high at 5% to 32%. The outcome of peripartum cardiomyopathy is also highly variable. For some women, the clinical and echocardiographic status improves and sometimes returns to normal, whereas for others, the disease progresses to severe cardiac failure and even sudden cardiac death. In acute care, treatment may involve the use of intravenous vasodilators, inotropic medications, an intra-aortic balloon pump, ventricular-assist devices, and/or extracorporeal membrane oxygenation. Survivors of peripartum cardiomyopathy often recover from left ventricular dysfunction; however, they may be at risk for recurrence of heart failure and death in subsequent pregnancies. Women with chronic left ventricular dysfunction should be managed according to guidelines of the American College of Cardiology Foundation and the American Heart Association.

Clinical characteristics of peripartum cardiomyopathy in the United States: diagnosis, prognosis, and management

Peripartum cardiomyopathy is a pregnancy-associated myocardial disease characterized by the development of heart failure due to marked left ventricular systolic dysfunction. Although the disease is relatively uncommon, its incidence is increasing, and it can be associated with important and lasting morbidity and with mortality. Peripartum cardiomyopathy seems to affect women in different parts of the world but with considerable differences in clinical presentation. The purposes of this review are to describe the clinical profile of peripartum cardiomyopathy in the United States and to provide recommendations for the diagnosis and the management of this disease.

[The heart during pregnancy]

During pregnancy, there are a number of important changes to cardiovascular function which are necessary for progression of a successful pregnancy. Additionally, preexisting cardiovascular conditions can be exacerbated by the adaptations that occur during gestation. These can present serious therapeutic challenges in the management of the cardiology patient during pregnancy. Significantly, the number of pregnant women at risk of cardiovascular complications is on the rise, so identification of risk factors that predict cardiac outcomes is essential to proper screening of the obstetrical patient. In diagnosed preexisting conditions, such as pulmonary hypertension, counseling is important prior to pregnancy. In the case of underlying disorders unmasked by pregnancy, or new-onset complications like preeclampsia, appropriate monitoring and treatment of the cardiovascular complications is warranted. Ultimately, collaborative care by both obstetricians and cardiologists is essential for the successful resolution of cardiovascular dysfunction in the obstetrical patient.

Recovery from peripartum cardiomyopathy in a Japanese woman after administration of bromocriptine as a new treatment option

Peripartum cardiomyopathy (PPCM) is a form of heart failure that occurs in women within 1 month before delivery and 5 months after delivery. The outcome of PPCM is variable but improves significantly when appropriate medication is administered in the acute phase; furthermore, the outcome does not worsen even after discontinuation of therapy in the chronic phase. The symptoms and signs of PPCM are similar to those of idiopathic dilated cardiomyopathy. The medical management of patients with PPCM is similar to that for other other forms of heart failure. Recent experimental data implicate a casual role of prolactin in the development of PPCM. Prolactin secretion can be reduced with bromocriptine which had beneficial effects in a small study. We present a Japanese woman with acute PPCM treated with bromocriptine as a therapeutic option. Following treatment, the serum prolactin levels dropped swiftly. Concurrently, LV function improved, and heart failure symptoms decreased, accompanied by a decrease in the BNP level.

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.

Different characteristics of peripartum cardiomyopathy between patients complicated with and without hypertensive disorders. -Results from the Japanese Nationwide survey of peripartum cardiomyopathy-

BACKGROUND

There has been no nationwide survey concerning peripartum cardiomyopathy (PPCM) among the Asian population, and clinical profiles of PPCM complicated with hypertensive disorders complicating pregnancy (HD) as the major risk factor of PPCM have not been characterized.

METHODS AND RESULTS

A retrospective, nationwide survey of PPCM in 2007 and 2008 all over Japan was performed and the clinical characteristics were compared between patients with and without HD. We obtained data for 102 patients. HD during pregnancy occurred in 42 patients (41%). Patients with HD were older than those without HD (33.8 vs. 31.9 years old, P<0.05) and babies were delivered more frequently by Caesarean section (81% vs. 52%, P<0.01). Although cardiac parameters at diagnosis were similar in patients with and without HD, patients with HD were hospitalized for a shorter period and had better cardiac function after 7 months. Multivariate regression analysis revealed that HD was independently associated with a shorter hospital stay and a higher left ventricular ejection fraction at last follow up.

CONCLUSIONS

PPCM complicated with HD had different clinical characteristics from those without HD. This condition might be a unique subset of PPCM that is characterized by relatively swift recovery except in the cases of death. In order to prevent severe heart failure and maternal death, peripartum women should be treated with HD cautiously and must immediately undergo a cardiac examination as needed.

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.

Update on peripartum cardiomyopathy

Although multiple mechanisms have been postulated, peripartum cardiomyopathy (PPCM) continues to be a cardiomyopathy of unknown cause. Multiple risk factors exist and the clinical presentation does not allow differentiation among potential causes. Although specific diagnostic criteria exist, PPCM remains a diagnosis of exclusion. Treatment modalities are dictated by the clinical state of the patient, and prognosis is dependent on recovery of function. Randomized controlled trials of novel therapies, such as bromocriptine, are needed to establish better treatment regimens to decrease morbidity and mortality. The creation of an international registry will be an important step to better define and treat PPCM. This article discusses the pathogenesis, risk factors, diagnosis, management, and prognosis of this condition.

"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.

Predictors of left ventricular recovery in a cohort of peripartum cardiomyopathy patients recruited via the internet

BACKGROUND

Peripartum cardiomyopathy (PPCM) is the onset of acute heart failure without demonstrable cause during the last month of pregnancy or within five months after delivery. The purpose of this study was to create a prospective registry of PPCM patients with the assistance of the internet and identify clinical factors predictive of ejection fraction (EF) recovery.

METHODS

Patients with PPCM were identified by novel web-based methods. Subjects were categorized as recovered (EF>50) or nonrecovered (EF<50) and compared on the basis of demographic and clinical variables.

RESULTS

Fifty-five subjects met criteria for inclusion. There was a statistically significant association between diagnosis during third trimester and persistent systolic dysfunction (25% vs. 4.7%, p=0.03). Gestational hypertension and breastfeeding were significantly associated with EF recovery (48.8% vs. 16.7%, p=0.046, and 39.5% vs. 8.3%, p=0.04, respectively). EF normalization occurred in all patients with EF(1) ≥ 35%.

CONCLUSIONS

Presence of gHTN, EF ≥ 35% at diagnosis, breastfeeding, and postpartum diagnosis were all significantly associated with recovery of systolic function. Internet recruitment may be a valuable tool for studying PPCM.

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.

Evaluation of bromocriptine in the treatment of acute severe peripartum cardiomyopathy: a proof-of-concept pilot study

BACKGROUND

Peripartum cardiomyopathy (PPCM) is a potentially life-threatening heart disease that occurs in previously healthy women. We identified prolactin, mainly its 16-kDa angiostatic and proapoptotic form, as a key factor in PPCM pathophysiology. Previous reports suggest that bromocriptine may have beneficial effects in women with acute onset of PPCM.

METHODS AND RESULTS

A prospective, single-center, randomized, open-label, proof-of-concept pilot study of women with newly diagnosed PPCM receiving standard care (PPCM-Std; n=10) versus standard care plus bromocriptine for 8 weeks (PPCM-Br, n=10) was conducted. Because mothers receiving bromocriptine could not breast-feed, the 6-month outcome of their children (n=21) was studied as a secondary end point. Blinded clinical, hemodynamic, and echocardiographic assessments were performed at baseline and 6 months after diagnosis. Cardiac magnetic resonance imaging was performed 4 to 6 weeks after diagnosis in PPCM-Br patients. There were no significant differences in baseline characteristics, including serum 16-kDa prolactin levels and cathepsin D activity, between the 2 study groups. PPCM-Br patients displayed greater recovery of left ventricular ejection fraction (27% to 58%; P=0.012) compared with PPCM-Std patients (27% to 36%) at 6 months. One patient in the PPCM-Br group died compared with 4 patients in the PPCM-Std group. Significantly fewer PPCM-Br patients (n=1, 10%) experienced the composite end point of poor outcome defined as death, New York Heart Association functional class III/IV, or left ventricular ejection fraction <35% at 6 months compared with the PPCM-Std patients (n=8, 80%; P=0.006). Cardiac magnetic resonance imaging revealed no intracavitary thrombi. Infants of mothers in both groups showed normal growth and survival.

CONCLUSIONS

In this trial, the addition of bromocriptine to standard heart failure therapy appeared to improve left ventricular ejection fraction and a composite clinical outcome in women with acute severe PPCM, although the number of patients studied was small and the results cannot be considered definitive. Larger-scale multicenter and blinded studies are in progress to test this strategy more robustly.

Bromocriptine treatment associated with recovery from peripartum cardiomyopathy in siblings: two case reports

INTRODUCTION

Peripartum cardiomyopathy is a rare form of cardiomyopathy, with heterogeneous presentation occurring in women between one-month antepartum and six months postpartum. It carries a poor prognosis and a high risk of mortality.

CASE PRESENTATION

We report the development of peripartum cardiomyopathy in two sisters, 27- and 35-year-old African women, one of whom presented with a large left ventricular thrombus. Subsequently, both patients were treated with bromocriptine, heparin and standard therapy for heart failure (angiotensin converting enzyme inhibitors, beta-blockers and diuretics). During follow-up, the left ventricular thrombus observed in one patient degraded. Neither patient experienced a thrombotic event, and both experienced continuous improvements in cardiac function and New York Heart Association stage.

CONCLUSION

The development of peripartum cardiomyopathy in two sisters indicates that there may be a genetic basis for this type of cardiomyopathy, and that women with a positive family history for peripartum cardiomyopathy may have an increased risk of developing the disease. This is also the first report of a patient experiencing degradation of a large left ventricular thrombus under standard therapy for heart failure with bromocriptine. It suggests that the use of bromocriptine in association with adequate anti-coagulation and heart failure therapy may be beneficial and safe.

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.

Peripartum cardiomyopathy: an intriguing challenge. Case report with literature review

Peripartum cardiomyopathy is a relatively rare disease, which can have devasting consequences and should be promptly identified and correctly treated. Overall prognosis is good in majority of the cases, although some patients may progress to irreversible heart failure. Early diagnosis is important and effective treatment reduces mortality rates and increases the chance of complete recovery of ventricular systolic function.We report of an interesting case with a favourable outcome and discuss about the clinical presentation, therapy and outcome of this condition.

Long-term outcome of peripartum cardiomyopathy in a population with high seropositivity for human immunodeficiency virus

BACKGROUND

Peripartum cardiomyopathy (PPCM) is a rare cardiomyopathy with a high risk of mortality. The present study assessed clinical outcome and mortality over a 2-year period in an African cohort of 80 PPCM patients.

METHODS

A prospective study over a 2-year period at a tertiary center, where 80 consecutive women presenting with PPCM were enrolled on first diagnosis. Patients obtained standard heart failure therapy. Detailed assessments included echocardiography, NYHA functional class, left ventricular ejection fraction (LVEF), mortality and serum levels for hemoglobin, CRP, IL-6, TNF-alpha, Fas/Apo-1, and T-cell count at each 6-month intervals for 24 months.

RESULTS

Baseline mean age was 30 ± 7 years; 38% were primigravidas and 34% were co-infected with HIV. NYHA functional class III-IV was present in 89% patients with a mean LVEF of 30 ± 9%. Four patients were lost to follow-up, 9 moved to remote areas, 7 were excluded due to subsequent pregnancy. The 2-year mortality rate was 28%. Eight of 80 (10%) died by 6 months. Mean LVEF of surviving patients was: 44 ± 11% at 6-months, 46 ± 13% at 12-months and 50 ± 14% at 24-months follow-up. Of the 69 patients still enrolled at 6 months 14 (20%) died over the remaining 18-month period, despite functional recovery. No statistically significant difference in LVEF and mortality was observed between PPCM patients with or without HIV co-infection.

CONCLUSION

The novel finding of this study is the continuous high mortality of PPCM patients occurring beyond 6 months independent of HIV infection and subsequent pregnancy. This finding strongly encourages the need for long-term clinical follow-up and management of women with PPCM.

Poor outcome of indigent patients with peripartum cardiomyopathy in the United States

OBJECTIVE

Peripartum cardiomyopathy (PPCM) patients from Haiti and South Africa have poor survival and poor left ventricular (LV) function recovery compared with patients from the United States. There are no reported studies of PPCM among the African American population in the United States. We evaluated the prognosis of PPCM in a mostly African American population.

STUDY DESIGN

We analyzed the clinical and echocardiographic data of 44 (39 African American) patients with PPCM over an 11 year period (1992-2003).

RESULTS

Thirty-nine patients were indigent and 5 had health insurance. During a mean follow-up of 24.0 (range, 0.1-264) months, 7 (15.9%) patients died and LV function returned to normal in 14 (35%).

CONCLUSION

LV function recovery and survival rates of PPCM patients observed in our study are similar to those reported from Haiti and South Africa and different from what is generally accepted in the United States.