Peripartum cardiomyopathy: inflammatory markers as predictors of outcome in 100 prospectively studied patients

"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.

Peripartum cardiomyopathy: case reports

Peripartum cardiomyopathy (PPCM) is a dilated cardiomyopathy defined as systolic cardiac heart failure in the last month of pregnancy or within five months of delivery. PPCM, which affects thousands of women each year in the US, was first described in the 1800s, yet its etiology is still unclear. Its diagnosis is often delayed because its symptoms closely resemble those within the normal spectrum of pregnancy and the postpartum period. When PPCM is misdiagnosed or its diagnosis is delayed, the consequences for patients are deadly: The disorder carries a high mortality rate.

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.

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: 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.

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.

Epidemiology of heart failure in sub-Saharan Africa

Heart failure has emerged as a dominant form of cardiovascular disease in Africa, and has great social and economic relevance owing to its high prevalence, mortality and impact on young, economically active individuals. The causes of heart failure in Africans remain largely nonischemic. Hypertension, cardiomyopathy, rheumatic heart disease, chronic lung disease and pericardial disease are the main contributors to the etiology of cardiac failure in sub-Saharan Africa, accounting for over 90% of cases. Hypertensive heart disease complications occur more frequently in Africans and the majority of affected patients are younger. Endemic cardiomyopathies include dilated cardiomyopathy, peripartum cardiomyopathy and endomyocardial fibrosis. Nonendemic cardiomyopathies apparently occur with the same frequency as in other parts of the world, and include hypertrophic cardiomyopathy and arrhythmogenic right ventricular dysplasia/cardiomyopathy. Coronary artery disease and its complications remain uncommon in Africa, but the situation is changing due to modifications in lifestyle, risk-prone behavior, diet, cultural attitudes and other consequences of rapid urbanization. As the prevalence of heart failure is expected to rise substantially in sub-Saharan Africa, the authors call for population-based studies and registries of the epidemiology of heart failure in Africans and the urgent study of interventions that will decrease morbidity and mortality from the causes of heart failure, with a focus both on nonischemic and ischemic risk factors.

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.

[Peripartum cardiomyopathy: incidence, pathogenesis, diagnosis, treatment and prognosis]

INTRODUCTION

Peripartum cardiomyopathy (PPCM) is a rare and life-threatening disease of unknown aetiology. The primary objective of this review was to analysed aetiopathogeneses, clinical presentation and diagnosis, as well as pharmacological, perioperative and intensive care management and prognosis of this pathology.

METHODS

We undertook a systematic review of the literature using Medline, Google Scholar and PubMed searches.

RESULTS

Unlike other parts of the world in which cardiomyopathy are rare, dilated cardiomyopathy is a major cause of heart failure throughout Africa. Its aetiopathogenesis is still poorly understood, but recent evidence supports inflammation, viral infection and autoimmunity as the leading causative hypotheses. This diagnosis should be limited to previously healthy women who present with congestive heart failure (CHF) and decreased left ventricular systolic function in the last month of pregnancy or within 5 months after delivery. Recently, introduction of echocardiography has made diagnosis of PPCM easier and more accurate. Conventional treatment consists of diuretics, vasodilators, and sometimes digoxin and anticoagulants, usually in combination. Patients who fail to recover may require inotropic therapy. In resistant cases, newer therapeutic modalities such as immunomodulation, immunoglobulin and immunosuppression may be considered. Prognosis is highly related to reversal of ventricular dysfunction. Compared to historically higher mortality rates, recent reports describe better outcome, probably because of advances in medical care. Based on current information, future pregnancy is usually not recommended in patients who fail to recover normal heart function.

CONCLUSION

PPCM is a rare but serious form of cardiac failure affecting women in the last months of pregnancy or early puerperium. Its aetiopathogenesis is still poorly understood. Introduction of echocardiography has made diagnosis of PPCM easier and more accurate. Prognosis is highly related to reversal of ventricular dysfunction.

Peripartum cardiomyopathy: recent insights in its pathophysiology

Peripartum/Postpartum cardiomyopathy (PPCM) is a serious, potentially life-threatening heart disease of uncertain etiology in previously healthy women. Previous clinical and experimental data have identified inflammation, autoimmune processes, apoptosis, and impaired cardiac (systemic) microvasculature as typical features in the pathophysiology of PPCM. However, recent data have shown that unbalanced peri/postpartum oxidative stress is linked to proteolytic cleavage of the nursing hormone prolactin into a potent antiangiogenic, proapoptotic, and pro-inflammatory factor. These observations strongly suggest that prolactin cleavage can operate as a specific pathomechanism for the development of PPCM. Consistent with these findings, inhibition of prolactin secretion by bromocriptine, a dopamine D2 receptor agonist, prevented the development of PPCM in an animal model of PPCM, and first clinical experience are promising in this respect. Thus, inhibition of prolactin release may represent a novel specific therapeutic approach to either prevent or treat patients with acute PPCM. In this review, we are highlighting the current knowledge on risk factors, potential pathomechanisms, and treatment options for PPCM.

Postpartum cardiomyopathy: a cardiac emergency for gynecologists, general practitioners, internists, pulmonologists, and cardiologists

INTRODUCTION

Peri- or postpartum cardiomyopathy (PPCM) is a rare, life-threatening heart disease of unclear origin and is characterized by heart failure of sudden onset between the final weeks of pregnancy and 6 months after delivery.

METHODS

Selective literature search in the databases of the National Center for Biotechnology Information based on the key words "peri- and postpartum cardiomyopathy," "pregnancy" and "heart failure" and additional information from the authors' personal experience.

RESULTS

PPCM is often not diagnosed until late in its course, because its clinical manifestations are highly variable and a heart disease may not be suspected at first. Frequent presenting symptoms of PPCM, such as prostration, shortness of breath on mild exertion, and coughing, are often initially misinterpreted as evidence of pneumonia or as physiological accompaniments of pregnancy and delivery. The clinical picture of PPCM corresponds to a dilated cardiomyopathy (DCM) with signs of severe heart failure. Therefore, treatment with ACE inhibitors, diuretics, aldosterone antagonists, and beta-blockers is required. Recent research findings suggest a possible new approach to the treatment of PPCM with bromocriptine, which inhibits the release of prolactin, a lactation-promoting hormone. To date, only the treatment of heart failure in PPCM is evidence-based, while all other treatments are "level C," i.e., based on expert opinion only.

CONCLUSION

The early diagnosis and interdisciplinary management of PPCM can often lead to substantial recovery from heart failure and cardiomyopathy.

Molecular diagnosis of the viral component in cardiomyopathies: pathophysiological, clinical and therapeutic implications

BACKGROUND

Myocarditis is defined as the inflammation of myocardium associated with cardiac dysfunction. Despite this clear-cut definition, diagnosis and etiologic treatment continue to create considerable debate. Viral infections are frequent causes of myocarditis and there is evidence that persistent viral infection is associated with poor prognosis in different subtypes of cardiomyopathy.

OBJECTIVE

To review methods for diagnosis of viral myocarditis and present the use of polymerase chain reaction (PCR)-based protocols for evaluating viral infection in myocarditis/cardiomyopathies.

METHODS

A review of published literature.

RESULTS/CONCLUSION

There is increasing evidence that PCR-based protocols can provide reliable molecular evidence for the presence of viral infection in myocardium. Thus application of molecular techniques will allow collection and analysis of more information on the epidemiology of viral cardiomyopathies, patient risk stratification and appropriate medical treatment.

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.

Factors associated with poor prognosis among patients admitted with heart failure in a Nigerian tertiary medical centre: a cross-sectional study

BACKGROUND

Heart failure is a major and growing public health problem worldwide. The prognosis of Heart Failure (HF) is uniformly poor despite advances in treatment. The aims of the present study were to determine the causes of HF among patients admitted to a Nigerian tertiary medical centre, to determine the prevalence of factors known to be associated with poor prognosis among these patients, and to compare the factors and causes between males and females.

METHODS

The study was cross-sectional in design, carried out on eligible patients who were consecutively admitted with HF, in Aminu Kano Teaching Hospital, Kano, Nigeria. The following established factors associated with poor prognosis of HF were assessed: low Left Ventricular Ejection Fraction (LVEF) of < or = 40%, anaemia, renal impairment, cardiac rhythm disturbances on the electrocardiogram, prolonged corrected QT interval (QTc), complete Left Bundle Branch Block (LBBB) and advanced age.

RESULTS

A total of 79 patients were studied over a six-month period. Forty four (55.7%) of these patients were males while the remaining 35 (44.3%) were females. The most prevalent prognostic factor was low LVEF found in a total of 35 patients (44.3%), while the least prevalent was complete LBBB found in two male patients only (2.53%). The commonest cause of heart failure in all patients and males was hypertensive heart disease, found in a total of 45 patients (57.0%), comprising of 33 male (73.3%) and 12 female patients (26.7%) (p = 0.0003). Cardiomyopathies were the commonest causes in females, the predominant type being peripartum cardiomyopathy found in 11 (31.4%) female patients. Acute myocardial infarction has emerged to be an important cause of HF in males (13.6%) with a high in-hospital mortality of 66.7%.

CONCLUSION

The most prevalent factor associated with poor prognosis was low LVEF. Hypertensive heart disease and cardiomyopathies were the most common causes of HF in males and females respectively. The findings of the study should guide decision-making regarding management of HF patients.

Peripartum cardiomyopathy: review of the literature

Peripartum cardiomyopathy (PPCM) is a rare but serious form of cardiac failure affecting women in the last months of pregnancy or early puerperium. Clinical presentation of PPCM is similar to that of systolic heart failure from any cause, and it can sometimes be complicated by a high incidence of thromboembolism. Prior to the availability of echocardiography, diagnosis was based only on clinical findings. Recently, inclusion of echocardiography has made diagnosis of PPCM easier and more accurate. Its etiopathogenesis is still poorly understood, but recent evidence supports inflammation, viral infection and autoimmunity as the leading causative hypotheses. Prompt recognition with institution of intensive treatment by a multidisciplinary team is a prerequisite for improved outcome. Conventional treatment consists of diuretics, beta blockers, vasodilators, and sometimes digoxin and anticoagulants, usually in combination. In resistant cases, newer therapeutic modalities such as immunomodulation, immunoglobulin and immunosuppression may be considered. Cardiac transplantation may be necessary in patients not responding to conventional and newer therapeutic strategies. The role of the anesthesiologist is important in perioperative and intensive care management. Prognosis is highly related to reversal of ventricular dysfunction. Compared to historically higher mortality rates, recent reports describe better outcome, probably because of advances in medical care. Based on current information, future pregnancy is usually not recommended in patients who fail to recover heart function. This article aims to provide a comprehensive updated review of PPCM covering etiopathogeneses, clinical presentation and diagnosis, as well as pharmacological, perioperative and intensive care management and prognosis, while stressing areas that require further research.

Contemporary trends in the epidemiology and management of cardiomyopathy and pericarditis in sub-Saharan Africa

Heart failure in sub-Saharan Africans is mainly due to non-ischaemic causes, such as hypertension, rheumatic heart disease, cardiomyopathy and pericarditis. The two endemic diseases that are major contributors to the clinical syndrome of heart failure in Africa are cardiomyopathy and pericarditis. The major forms of endemic cardiomyopathy are idiopathic dilated cardiomyopathy, peripartum cardiomyopathy and endomyocardial fibrosis. Endomyocardial fibrosis, which affects children, has the worst prognosis. Other cardiomyopathies have similar epidemiological characteristics to those of other populations in the world. HIV infection is associated with occurrence of HIV-associated cardiomyopathy in patients with advanced immunosuppression, and the rise in the incidence of tuberculous pericarditis. HIV-associated tuberculous pericarditis is characterised by larger pericardial effusion, a greater frequency of myopericarditis, and a higher mortality than in people without AIDS. Population-based studies on the epidemiology of heart failure, cardiomyopathy and pericarditis in Africans, and studies of new interventions to reduce mortality, particularly in endomyocardial fibrosis and tuberculous pericarditis, are needed.

Postpartum depression, an autoimmune disease?

Medical conditions with known etiology and typical peripartal/postpartal disease exacerbations are now, without exception, considered autoimmune in etiology. Postpartum psychiatric conditions, and especially postpartum depression, currently, however, are still not understood in their etiology. This paper suggests that the typical postpartum flare pattern, and other clinical characteristics, point towards an autoimmune etiology for (postpartum) depression. The high prevalence of (postpartum) depression led to its designation as a major public health problem. A better understanding of etiology and pathophysiology would greatly advance the, currently still inaccurate, diagnosis of the condition, and improve approaches towards prevention and treatment.

Clinical and immunologic characteristics in peripartum cardiomyopathy

Peripartum cardiomyopathy (PPCM) is a rare disorder of dilated cardiomyopathy and left ventricular dysfunction occurring in the last month of pregnancy or within 5 months postpartum. Outcome of PPCM is highly variable, comprising clinical improvement and rapid deterioration unresponsive to medical treatment requiring heart transplantation or even death. In this study, we report the clinicopathologic findings of 10 patients with PPCM who were retrospectively identified in our cardiomyopathy registry. During a follow-up of 69+/-27 months, no patient died or required orthotopic heart transplantation. Left ventricular ejection fraction was 38+/-7% at the time of diagnosis and 53+/-7% during follow-up. While all patients had sinus rhythm at the time of diagnosis, three patients presented with left bundle branch block. We found no evidence of viral infection in endomyocardial biopsy samples of seven patients by PCR. Histopathologic findings revealed the presence borderline myocarditis in two of seven patients (29%). Circulating autoantibodies to cardiac tissue of any kind were observed in all patients. In conclusion, in our retrospective observational study, no patient diagnosed with PPCM died or received orthotopic heart transplantation. Improvement of left ventricular ejection fraction was present in eight patients (80%), while LV dysfunction persisted in four patients. Our findings support the hypothesis of an underlying autoimmune pathomechanism in this rare disease.

WITHDRAWN: Cardiac Troponin T: An Early Molecule Marker of Normalization of Left Ventricular Ejection Fraction in Patients with Peripartum Cardiomyopathy

The article entitled, "Cardiac Troponin T: An Early Molecule Marker of Normalization of Left Ventricular Ejection Fraction in Patients with Peripartum Cardiomyopathy", by Li et al, which originally was published in this space, has been removed because an article by the same authors and reporting very similar work already has been published in HEART [Published Online First: 25 October 2006], entitled, "Troponin T measurement can predict persistent left ventricular dysfunction in peripartum cardiomyopathy", by Hu et al. The printed version of the article in HEART can be found at Heart 2007;93:488-490.

Peripartum cardiomyopathy: a comprehensive review

Peripartum cardiomyopathy (PPCM) is a rare disorder in which left ventricular dysfunction and symptoms of heart failure occur in the peripartum period in previously healthy women. Incidence of PPCM ranges from 1 in 1300 to 1 in 15,000 pregnancies. The etiology of PPCM is unknown, but viral, autoimmune, and idiopathic causes may contribute. The diagnostic criteria are onset of heart failure in the last month of pregnancy or in first 5 months postpartum, absence of determinable cause for cardiac failure, and absence of a demonstrable heart disease before the last month of pregnancy. Risk factors for PPCM include advanced maternal age, multiparity, African race, twinning, gestational hypertension, and long-term tocolysis. The clinical presentation of patients with PPCM is similar to that of patients with dilated cardiomyopathy. Early diagnosis and initiation of treatment are essential to optimize pregnancy outcome. Treatment is similar to medical therapy for other forms of dilated cardiomyopathy. About half the patients of PPCM recover without complications. The prognosis is poor in patients with persistent cardiomyopathy. Persistence of disease after 6 months indicates irreversible cardiomyopathy and portends worse survival.

Troponin T measurement can predict persistent left ventricular dysfunction in peripartum cardiomyopathy

OBJECTIVE

To determine whether measurement of cardiac troponin T (cTnT) concentration in newly diagnosed peripartum cardiomyopathy (PPCM) can be used to predict persistent left ventricular dysfunction after a 6-month follow-up.

PATIENTS AND METHODS

This was a prospective, multiple-centre clinical trial that studied 106 patients with newly diagnosed PPCM surviving over 6 months. cTnT concentration was measured within 2 weeks of the onset of PPCM.

RESULTS

Serum cTnT concentration was negatively correlated with left ventricular ejection fraction (LVEF) at follow-up (LVEF, r = -0.518, p = 0.0001). Analysis by receiver operator characteristic curve yielded an area under the curve of 0.764 (95% CI 0.669 to 0.860, p = 0.0001, vs null hypothesis value 0.5) for cTnT, and a cTnT concentration cut off of >0.04 ng/ml, predicting persistent left ventricular dysfunction with a sensitivity of 54.9% and a specificity of 90.9%. Among 106 recruited patients, there were 33 patients with cTnT concentrations >0.04 ng/ml and 73 patients with cTnT concentrations < or =0.04 ng/ml. After a 6-month follow-up, there was significantly smaller LVEF (35.42% (13.04% vs 50.16% (10.48%, p = 0.0001) and more persistent left ventricular dysfunction (84.8% vs 31.5%, OR = 12.17 (95% CI 4.17 to 35.57), p = 0.001) in patients with cTnT >0.04 ng/ml than in patients with cTnT < or =0.04 ng/ml.

CONCLUSION

Serum cTnT concentration measured within 2 weeks of the onset of PPCM was correlated negatively with LVEF at follow-up. This marker offers a simple, quick, inexpensive, non-invasive method for predicting a persistent LVEF of < or =50%. A cTnT concentration of >0.04 ng/ml predicted persistent left ventricular dysfunction with a sensitivity of 54.9% and a specificity of 90.9%.

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.