Assessment of major mental disorders in a German peripartum cardiomyopathy cohort

Panic disorder during pregnancy and the first three years after delivery: a systematic review

BACKGROUND

Panic disorder (PD) is highly prevalent during the peripartum period. The aim of this systematic review was to summarize evidence on risk factors and course patterns of peripartum PD as well as maternal, infant or dyadic outcomes during the first three years after delivery.

METHODS

A literature search was conducted according to PRISMA guidelines. Inclusion criteria were: (1) a diagnosis of PD or panic attacks during pregnancy, (2) risk factors and course as well as maternal, infant or dyadic outcomes measured in pregnancy and/or up to 3 years postpartum (3) peer-reviewed articles in English or German published between 1980 and April 2024. After screening of n = 2,740 records, n = 75 records based on n = 64 projects were eligible for this systematic review.

RESULTS

Overall, n = 47 studies investigated the course of PD during the peripartum period, n = 23 studies examined the associations of PD and obstetric, neonatal or infant outcomes, and n = 5 studies focused on the associations of PD and characteristics of the mother-infant dyad. We found (1) no common trajectory, but heterogeneous courses of maternal PD in the peripartum period, (2) associations of maternal PD with birth complications and subsequent postpartum depression, and (3) evidence for associations of PD with infant and dyadic outcomes.

LIMITATIONS

Diverse outcome measures in recent original publications did not allow for a meta-analytic approach.

CONCLUSION

Heterogenous courses and outcomes of peripartum PD require comprehensive monitoring of affected mothers and their infants. There is a need for further longitudinal investigations into familial transmission of anxiety disorders.

Peripartum heart failure in Finland: A population-based record linkage study

AIMS

Heart failure in late pregnancy and the postpartum period (HFPP) is a rare but potentially life-threatening condition, with peripartum cardiomyopathy (PPCM) being the most common subtype. This study aims to comprehensively investigate the prevalence of HFPP in the Finnish population and identify the underlying risk factors associated with its occurrence.

METHODS

We conducted a retrospective analysis using data from the Finnish Medical Birth Register and the Finnish Care Register for Health Care, covering 1996 to 2021. The dataset comprised 1 387 457 deliveries. HFPP cases were identified based on specific ICD-10 codes. To ensure the accuracy of our findings, we excluded cases with pre-existing cardiomyopathies and other significant cardiac diseases diagnosed before pregnancy. We employed logistic regression models to evaluate the associations between maternal factors and the incidence of HFPP.

RESULTS

We identified 159 cases of HFPP, resulting in an incidence rate of 11.5 per 100 000 deliveries. This incidence is comparable with rates reported in other Scandinavian countries and lower than those observed in Germany. Consistent with findings from European cohorts, our study confirmed that pregnancy-associated hypertensive disorders, particularly preeclampsia, as well as complications such as preterm delivery, twin pregnancy and elective caesarean section, are substantial risk factors for HFPP. These results support previous research linking angiogenic imbalance to the pathogenesis of PPCM. Significant risk factors for HFPP included maternal pre-pregnancy body mass index ≥35 [adjusted odds ratio (aOR) 2.04, 95% confidence interval (CI) 1.28-3.25, P = 0.003], history of maternal hypertensive disorder (aOR 2.44, 95% CI 1.22-4.88, P = 0.012), gestational hypertension without significant proteinuria (aOR 2.14, 95% CI 1.27-3.61, P = 0.004), preeclampsia (aOR 2.43, 95% CI 1.39-4.23, P = 0.002), type 1 or type 2 diabetes (aOR 3.27, 95% CI 1.66-6.45, P < 0.001) and twin pregnancy (aOR 2.74, 95% CI 1.37-5.49, P = 0.005). Additionally, extensive prepartum [odds ratio (OR) 2.86, 95% CI 1.18-6.98, P = 0.018] and postpartum blood loss (OR 2.50, 95% CI 1.44-5.02, P = 0.001) and maternal mental disorders (OR 7.39, 95% CI 4.10-13.31, P < 0.001) were significantly more common among HFPP patients.

CONCLUSIONS

The incidence of HFPP among women in Finland from 1996 to 2021 was low. HFPP exhibited a strong association with several risk factors, including preeclampsia, obesity, preterm delivery, twin pregnancy, elective caesarean section, multifoetal births, type 1 and type 2 diabetes, significant prepartum and postpartum blood loss and maternal mental health disorders. These findings underscore the importance of targeted interventions and careful monitoring in high-risk groups to mitigate the impact of HFPP on maternal health.

Living with peripartum cardiomyopathy: A statement from the Heart Failure Association and the Association of Cardiovascular Nursing and Allied Professions of the European Society of Cardiology

This statement focuses on the fact that women with peripartum cardiomyopathy (PPCM) have a substantial mortality and morbidity rate. Less than 50% of patients have full recovery of their cardiac function within 6 months of diagnosis. Also, patients with recovered cardiac function often suffer from comorbidities, such as hypertension or arrhythmias, which require long-term treatment. This has major implications which extend beyond the life of the patient, as it may also substantially impact her family. Women with a new diagnosis of PPCM should be involved in the decision-making processes regarding therapies, e.g. the recommendation to abstain from breastfeeding, or the use of cardiac implantable electronic devices. Women living with PPCM face the uncertainty of not knowing for some time whether their cardiac function will recover to allow them a near-to-normal life expectancy. This not only impacts their ability to work, which may have financial implications, but may also affect mental health and quality of life for the extended family. Women living with PPCM must be informed that a future pregnancy always carries a substantial risk and, in case of poor cardiac recovery, is associated with a high morbidity and mortality. Patients with PPCM are best managed by an interdisciplinary and multiprofessional approach including e.g. a cardiologist, a gynaecologist, nurses, a psychologist, and social workers. The scope of this document encompasses contemporary challenges and approaches for the management of women diagnosed with PPCM.

Adherence to heart failure treatment in patients with peripartum cardiomyopathy

AIMS

Peripartum cardiomyopathy (PPCM) is characterized by left ventricular (LV) dysfunction developing towards the end of pregnancy or in the first months postpartum. Although about 60% of women with PPCM (the majority of which are prescribed evidence based heart failure [HF] medications) show LV recovery within 6 to 12 months, others remain with persistently impaired LV function. Poor adherence to medical therapy represents a major cause of avoidable hospitalizations, disability, and death in other cardiovascular conditions. In this study, we aimed to determine drug adherence to HF therapy among women with PPCM and to identify possible associations between drug adherence and LV recovery, functional status and psychological well-being.

METHODS AND RESULTS

In this single-centre, prospective, observational study, we included 36 consecutive women with PPCM. Adherence to HF treatment was assessed by (i) verifying the collection of pharmacy refills and (ii) using liquid chromatography high-resolution mass spectrometry (LC-HRMS). Participants were thereby classified as 'adherent' (i.e. all prescribed HF drugs were detectable by LC-HRMS), 'partially adherent' (i.e. at least one prescribed drug detectable) or 'non-adherent' (i.e. none of the prescribed drugs detectable). Health state index scores were assessed by EQ-5D-5L and HADS-A/D (for anxiety/depression). Patients' median age was 32.4 years (IQR 27.6-36.1). At the adherence visit (which occurred at a median of 16 months [IQR 5-45] after PPCM diagnosis), prescription included beta-blockers (77.8%), angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (75%), mineralocorticoid receptor antagonists (47.2%) and loop diuretics (95.2%). Less than two thirds of patients (63.9%) collected all their pharmacy refills in the 6 months prior to adherence visit. According to LC-HRMS, 23.5% participants were classified as adherent, 53.0% as partially adherent, and 23.5% as non-adherent. Adherence was associated with significantly lower LVEDD at follow-up (47 mm [IQR 46-52), vs. 56 mm [IQR 49-64] with partial adherence, and 62 mm [IQR 55-64] with non-adherence, P = 0.022), and higher LVEF at follow-up (60% [IQR 41-65]), vs. partially adherence (46% [IQR 34-50]) and non-adherence (41.0% [IQR 29-47], P = 014). Adherent patients had a lower overall EQ- 5D score (5.5 [IQR 5-7.5], vs. 6 [IQR 5-7] in partially adherent, and 10 [IQR 8-15] in non-adherent patients, P = 0.032) suggestive of a better self-rated health status.

CONCLUSIONS

Adherence to HF therapy was associated with favourable LV reverse remodelling in PPCM and better self-rated health status. Our study highlights the importance of drug adherence for functional recovery. Drug adherence should be an important component of patient communication and specific interventions in PPCM.

Pregnancy, Reproductive Factors, and Female Heart Failure Risk and Outcomes

PURPOSE OF REVIEW

The purpose of this review is to provide an overview of recent evidence on female-specific risk factors related to reproductive status or pregnancy.

RECENT FINDINGS

Pregnancy-related factors, including hypertensive disorders and gestational diabetes, increase the risk of heart failure in women, while breastfeeding and hormone therapy may offer protection. Hypertensive disorders of pregnancy, gestational diabetes, polycystic ovarian syndrome, placental abruption, younger maternal age at first live birth, younger maternal age at last live birth, number of stillbirths, number of pregnancies, onset of menstruation before 12 years of age, shorter reproductive age, ovariectomy, and prolonged absence of ovarian hormones may increase the risk of heart failure in women. Conversely, breastfeeding status and hormone therapy (for menopause or contraception) may serve as protective factors, while fertility treatments have no discernible effect on the risk of heart failure.

Postpartum quality of life and mental health in women with heart disease: Integrated clinical communication and treatment

BACKGROUND

Postpartum quality of life (QoL) in women with heart disease has been neglected.

AIM

To improve clinical communication and treatment, we integrated medical data and subjective characteristics to study postpartum QoL concerns.

METHODS

The study assessed QoL 6 wk after birth using the 12-Item Short-Form Health Survey. The Edinburgh Postnatal Depression Scale, Cardiac Anxiety Questionnaire, European Heart Failure Self-Care Behavior Scale, and a self-designed questionnaire based on earlier research were also used to assess patient characteristics. Patient data were collected. Prediction models were created using multiple linear regression.

RESULTS

This retrospective study examined postpartum QoL in 105 cardiac patients. Postpartum QoL scores were lower (90.69 ± 13.82) than those of women without heart disease, with physical component scores (41.09 ± 9.91) lower than mental component scores (49.60 ± 14.87). Postpartum depression (33.3%), moderate anxiety (37.14%), pregnancy concerns (57.14%), offspring heart problems (57.14%), and life expectancy worries (48.6%) were all prevalent. No previous cardiac surgery, multiparity, higher sadness and cardiac anxiety, and fear of unfavorable pregnancy outcomes were strongly related to lower QoL (R2 = 0.525).

CONCLUSION

Postpartum QoL is linked to physical and mental health in women with heart disease. Our study emphasizes the need for healthcare workers to recognize the unique characteristics of these women while developing and implementing comprehensive management approaches during their maternity care.

Is self-advocacy universally achievable for patients? The experiences of Australian women with cardiac disease in pregnancy and postpartum

PURPOSE

Patient self-advocacy is valued and promoted; however, it may not be readily accessible to all. This analysis examines the experiences of women in Australia who had cardiac disease in pregnancy or the first year postpartum through the lenses of self-advocacy and gender, specifically seeking to elaborate on the contexts, impacts, barriers, and women's responses to the barriers to self-advocacy.

METHOD

A qualitative study design was used. Twenty-five women participated in semi-structured in-depth interviews. Data were analysed using thematic analysis.

RESULTS

Analysis of findings generated the following themes: 1) Silent dream scream, 2) Easier said than done, 3) Crazy-making, and 4) Concentric circles of advocacy. Regardless of women's personal attributes, knowledge and experience, self-advocating for their health was complex and difficult and had negative cardiac and psychological outcomes.

CONCLUSION

While the women encountered significant barriers to self-advocating, they were resilient and ultimately developed strategies to be heard and to advocate on their own behalf and that of other women. Findings can be used to identify ways to support women to self-advocate and to provide adequately resourced and culturally safe environments to enable healthcare professionals to provide person-centred care.

[Hypochondriasis in Graves' disease: the role of pathologic factors and clinical characteristics endocrinopathy]

OBJECTIVE

Clinical qualification of hypochondriasis or illness anxiety disorder (IAD) in Graves' disease (GD) and verification of associated personality and endocrinological factors.

MATERIAL AND METHODS

A sample consisted of 27 patients (25 female and 2 male, mean age 48.4 years) with GD and personality disorders (PDs). The patients were examined clinically and with interviews for the assessment of PD according to DSM-IV (SCID-II-PD) and the Short Health Anxiety Inventory (SHAI).

RESULTS

IAD was diagnosed in 8 cases (29.6%), of which the main study group was formed. The remaining 19 patients, who did not show signs of IAD, were assigned to the control group. In the main group, the average score on the SHAI «health anxiety» subscale was significantly higher (10.2 vs 4.8 points, p<0.05) corresponding to the clinical qualification of the condition as IAD. When assessing the frequency of categorical PDs, it was found that there were no affective PDs in the main group, likewise there were no anxiety cluster PDs in the control group (p<0.05). In turn, in the main group, PDs were characterized by such dimensions as the phenomena of psychopathological diathesis, reactive lability, neuropathy, which were not observed in the control group. The endocrinological factor that differed significantly in main and control groups was the frequency of recurrence of GD (75.0% vs, 40.1%, p<0.05).

CONCLUSION

Despite the generally relatively favourable prognosis of GD, there is a significant frequency of IAD, the key role in the formation of which is apparently played by the parameters of the premorbid characteristics, as well as GD recurrence.

Quality of life and mental health of women who had cardiac disease in pregnancy and postpartum

Purpose

Cardiac disease is a leading cause of maternal morbidity and mortality yet there is limited research on women’s experiences and quality of life (QoL) outcomes. The aim of this study is to explore the general and health-related QoL (HRQoL) and mental health outcomes for women who have experienced cardiac disease in pregnancy and the first 12 months postpartum (CDPP).

Methods

This exploratory descriptive study recruited 43 women with acquired, genetic and congenital CDPP. Patient reported outcomes measures (PROMs) used were: WHOQoL-Bref, a Kansas City Cardiac Questionnaire (KCCQ), the Depression, Anxiety and Stress Scales-21 (DASS-21), the Cardiac Anxiety Questionnaire (CAQ) plus newly developed questions.

Results

Women reported low health satisfaction (51.7/100), physical health (55.2/100) and low HRQoL (63.1/100). Women had clinically significant scores for depression (24%), anxiety (22%) and stress (19.5%) (DASS-21) and 44.5% scored at least moderate anxiety on the CAQ. Most women (83.7%) were advised to avoid pregnancy which 88.9% found “upsetting” to “devastating”; 10.0% were offered counselling. Most women were concerned about reduced longevity (88.1%), offspring developing a cardiac condition (73.8%), and the limitations on enjoyment of life (57.1%). Women missed medical appointments due to cost (25.03%) and difficulty arranging childcare (45.5%).

Conclusion

The majority of women reported inadequate information and counselling support, with women with CDPP having sustained impaired QoL and mental health outcomes. The new and modified questions relating to mothering and children reflected the primacy of mothering to women’s identity and needs.

Supplementary information

The online version contains supplementary material available at 10.1186/s12884-022-05123-x.

Cabergoline treatment promotes myocardial recovery in peripartum cardiomyopathy

AIMS

Peripartum cardiomyopathy (PPCM) is a rare heart disease, occurring in previously heart-healthy women during the last month of pregnancy or the first months after delivery due to left ventricular (LV) systolic dysfunction. A common pathomechanistic pathway of PPCM includes increased oxidative stress and the subsequent generation of a cleaved prolactin fragment (16 kDa PRL), which promotes the onset of heart failure (HF) in a microRNA (miR)-146a-dependent manner. Inhibition of prolactin secretion with the dopamine D2 receptor (D2R) agonist bromocriptine combined with standard HF therapy supports cardiac recovery. This study examined whether treatment with the more selective D2R agonist cabergoline prevents HF development in an experimental PPCM mouse model and might be used as an alternative treatment regime for PPCM.

METHODS AND RESULTS

Postpartum (PP) female PPCM-prone mice with a cardiomyocyte restricted STAT3-deficiency (αMHC-Cre^tg/+ ; Stat3^fl/fl ; CKO) were treated over two consecutive nursing periods with cabergoline (CKO Cab, 0.5 mg/kg/day) and were compared with bromocriptine treated CKO (CKO Br) and postpartum-matched WT and CKO mice. Cabergoline treatment in CKO PP mice preserved cardiac function [fractional shortening (FS): CKO Cab: 34.5 ± 9.4% vs. CKO: 22.1 ± 9%, P < 0.05] and prevented the development of cardiac hypertrophy, fibrosis, and inflammation as effective as bromocriptine therapy (FS: CKO Br: 33.4 ± 5.6%). The myocardial up-regulation of the PPCM biomarkers plasminogen inhibitor activator 1 (PAI-1) and miR-146a were prevented by both cabergoline and bromocriptine therapy. A small cohort of three PPCM patients from the German PPCM Registry was treated with cabergoline (1 mg per week for 2 weeks, followed by 0.5 mg per week for another 6 weeks) due to a temporary unavailability of bromocriptine. All PPCM patients initially presented with a severely reduced LV ejection fraction (LVEF: 26 ± 2%). However, at 6 months of follow-up, LV function (LVEF: 56 ± 2%) fully recovered in all three PPCM patients, and no adverse events were detected.

CONCLUSIONS

In the experimental PPCM mouse model, the selective D2R agonist cabergoline prevents the onset of postpartum HF similar to bromocriptine. In PPCM patients, cabergoline treatment was safe and effective as all patients fully recovered. Cabergoline might serve as a promising alternative to bromocriptine. However, these findings are based on experimental data and a small case series and thus have to be interpreted with caution and should be validated in a larger clinical trial.

Cardiac disease in pregnancy and the first year postpartum: a story of mental health, identity and connection

Background

Women with cardiac disease in pregnancy and the first year postpartum often face uncertainty about their condition and the trajectory of their recovery. Cardiac disease is a leading cause of serious maternal morbidity and mortality, and the prevalence is increasing. Affected women are at risk of worsening cardiac disease, chronic illness, mental illness and trauma. This compounded risk may lead to significant and long-term negative outcomes. The aim of this study is to correct the lack of visibility and information on the experiences of women with cardiac disease in pregnancy and the first year postpartum.

Methods

A qualitative study using in-depth semi-structured interviews with twenty-five women who had acquired, congenital or genetic cardiac disease during pregnancy or the first year postpartum. Data were analysed and interpreted using a thematic analysis framework.

Results

Analysis of the interviews produced three major themes: 1) Ground zero: index events and their emotional and psychological impact, 2) Self-perception, identity and worthiness, and 3) On the road alone; isolation and connection. There was a narrative consistency across the interviews despite the women being diverse in age, cardiac diagnosis and cardiac health status, parity and timing of diagnosis. The thread prevailing over the temporal and clinical differences was one of distress, biographical disruption, identity, isolation, a necessitated re-imagining of their lives, and the process of multi-layered healing.

Conclusion

Acknowledging and understanding the breadth, complexity and depth of women’s experiences is fundamental to improving outcomes. Our findings provide unique insights into women’s experiences and challenges across a spectrum of diseases. Most women did not report an isolated trauma or distressing event, rather there was a layering and persistence of psychological distress necessitating enhanced assessment, management and continuity of care beyond the routine 6-week postpartum check. Further research is required to understand long-term outcomes and to refine the findings for specific disease cohorts to be able to respond effectively.

Psychological and Psychopharmacological Interventions in Psychocardiology

Patients with mental disorders have an increased risk to develop cardiovascular disease (CVD), and CVD are frequently comorbid with especially adjustment, anxiety and depressive disorders. Therefore, clinicians need to be aware of effective and safe psychological and pharmacological treatment strategies for patients with comorbid CVD and mental disorders. Cognitive behavioral therapy and third-wave of cognitive-behavioral therapy are effective for patients with CVD and mental disorders. Internet-based psychological treatments may also be considered. In more severe cases, psychopharmacological drugs are frequently used. Although generally well tolerated and efficacious, drug- and dose-dependent side effects require consideration. Among antidepressants, selective serotonin reuptake inhibitors, selective serotonin and noradrenalin reuptake inhibitors, and newer antidepressants, such as mirtazapine, bupropion, agomelatine, and vortioxetine, can be considered, while tricyclic antidepressants should be avoided due to their cardiac side effects. Mood stabilizers have been associated with arrhythmias, and some first- and second-generation antipsychotics can increase QTc and metabolic side effects, although substantial differences exist between drugs. Benzodiazepines are generally safe in patients with CVD when administered short-term, and may mitigate symptoms of acute coronary syndrome. Laboratory and ECG monitoring is always recommended in psychopharmacological drug-treated patients with CVD. Presence of a heart disease should not exclude patients from necessary interventions, but may require careful risk-benefit evaluations. Effectively and safely addressing mental disorders in patients with CVD helps to improve both conditions. Since CVD increase the risk for mental disorders and vice versa, care providers need to screen for these common comorbidities to comprehensively address the patients' needs.

MicroRNAs as novel peripheral markers for suicidality in patients with major depressive disorder

OBJECTIVE

Major depressive disorder (MDD) constitutes a main risk factor for suicide. Suicide risk in psychiatric patients is primarily determined by often unreliable, self-reported information. We assessed serum levels of three microRNAs (miRNAs), previously demonstrated to be dysregulated in post-mortem brain samples of suicide victims, as potential peripheral biomarkers for suicidality.

METHODS

All study participants were diagnosed with MDD according to Diagnostic and Statistical Manual of Mental Disorders, 5th edition criteria. Suicidality, defined as acute suicide risk or suicide attempt within one week prior to study entry, was assessed by clinical interview. Relative serum levels of miR-30a, miR-30e, and miR-200a, normalized to U6, were measured by quantitative real-time PCR in MDD inpatients with (MDD/SI, N = 19) and without (MDD, N = 31) acute suicide risk. Median age and gender distribution were comparable in both groups.

RESULTS

Levels of miR-30a, miR-30e, and miR-200a were significantly elevated in MDD/SI compared to MDD. Subgroup analysis of the MDD/SI group showed that levels of miR-30e and miR-200a were significantly higher and miR-30a was increased by trend in patients admitted following a suicide attempt (N = 7) compared to patients with acute suicide risk but without recent suicide attempt (N = 12). Additionally, use of two databases for in silico transcription factor-miRNA interaction prediction indicated early growth response protein (EGR) 1 as potential transcriptional regulator for all three miRNAs.

CONCLUSION

This study demonstrates suicide risk in MDD patients to be associated with increased levels of miR-30a, miR-30e, and miR-200a. Thus, these miRNAs might constitute potential biomarkers to predict suicidal behavior in MDD patients.

Peripartum cardiomyopathy: from genetics to management

Peripartum cardiomyopathy (PPCM) is a disease that occurs globally in all ethnic groups and should be suspected in any peripartum women presenting with symptoms and signs of heart failure, towards the end of pregnancy or in the months following delivery, with confirmed left ventricular dysfunction. After good history taking, all women should be thoroughly assessed, and alternative causes should be excluded. Urgent cardiac investigations with electrocardiogram and natriuretic peptide measurement (if available) should be performed. Echocardiography follows as the next step in investigation. Patients with abnormal cardiac investigations should be urgently referred to a cardiology team for expert management. Referral for genetic work-up should be considered if there is a family history of cardiomyopathy or sudden death. PPCM is a disease with substantial maternal and neonatal morbidity and mortality. Maternal mortality rates range widely, from 0% to 30%, depending on the ethnic background and geographic region. Just under half of women experience myocardial recovery. Remarkable advances in the comprehension of the pathogenesis and in patient management and therapy have been achieved, largely due to team efforts and close collaboration between basic scientists, cardiologists, intensive care specialists, and obstetricians. This review summarizes current knowledge of PPCM genetics, pathophysiology, diagnostic approach, management, and outcome.

ERBB4 and Multiple MicroRNAs That Target ERBB4 Participate in Pregnancy-Related Cardiomyopathy

BACKGROUND

Peripartum cardiomyopathy (PPCM) is a life-threatening disease in women without previously known cardiovascular disease. It is characterized by a sudden onset of heart failure before or after delivery. Previous studies revealed that the generation of a 16-kDa PRL (prolactin) metabolite, the subsequent upregulation of miR-146a, and the downregulation of the target gene Erbb4 is a common driving factor of PPCM.

METHODS

miRNA profiling was performed in plasma of PPCM patients (n=33) and postpartum-matched healthy CTRLs (controls; n=36). Elevated miRNAs in PPCM plasma, potentially targeting ERBB4 (erythroblastic leukemia viral oncogene homolog 4), were overexpressed in cardiomyocytes using lentiviral vectors. Next, cardiac function, cardiac morphology, and PPCM phenotype were investigated after recurrent pregnancies of HZ (heterozygous) cardiomyocyte-specific Erbb4 mice (Erbb4^F/+ αMHC-Cre⁺, n=9) with their age-matched nonpregnant CTRLs (n=9-10).

RESULTS

Here, we identify 9 additional highly conserved miRNAs (miR-199a-5p and miR-199a-3p, miR-145a-5p, miR-130a-3p, miR-135a-5p, miR-221-3p, miR-222-3p, miR-23a-3p, and miR19b-3p) that target tyrosine kinase receptor ERBB4 and are over 4-fold upregulated in plasma of PPCM patients at the time of diagnosis. We confirmed that miR-146a, miR-199a-5p, miR-221-3p, miR-222-3p, miR-23a-3p, miR-130a-5p, and miR-135-3p overexpression decreases ERBB4 expression in cardiomyocytes (-29% to -50%; P<0.05). In addition, we demonstrate that genetic cardiomyocyte-specific downregulation of Erbb4 during pregnancy suffices to induce a variant of PPCM in mice, characterized by left ventricular dilatation (postpartum second delivery: left ventricular internal diameter in diastole, +19±7% versus HZ-CTRL; P<0.05), increased atrial natriuretic peptide (ANP) levels (4-fold increase versus HZ-CTRL mice, P<0.001), decreased VEGF (vascular endothelial growth factor) and VE-cadherin levels (-33±17%, P=0.07; -27±20%, P<0.05 versus HZ-CTRL), and histologically enlarged cardiomyocytes (+20±21%, versus HZ-CTRL, P<0.05) but without signs of myocardial apoptosis and inflammation.

CONCLUSIONS

ERBB4 is essential to protect the maternal heart from peripartum stress. Downregulation of ERBB4 in cardiomyocytes induced by multiple miRNAs in the peripartum period may be crucial in PPCM pathophysiology. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT00998556.

Heart and brain interactions : Pathophysiology and management of cardio-psycho-neurological disorders

Cardiovascular diseases (CVD) and mental health disorders (MHD; e.g. depression, anxiety and cognitive dysfunction) are highly prevalent and are associated with significant morbidity and mortality and impaired quality of life. Currently, possible interactions between pathophysiological mechanisms in MHD and CVD are rarely considered during the diagnostic work-up, prognostic assessment and treatment planning in patients with CVD, and research addressing bidirectional disease mechanisms in a systematic fashion is scarce. Besides some overarching pathogenetic principles shared by CVD and MHD, there are specific syndromes in which pre-existing neurological or psychiatric illness predisposes and contributes to CVD development (as in Takotsubo syndrome), or in which the distorted interplay between innate immune and central nervous systems and/or pre-existing CVD leads to secondary MHD and brain damage (as in peripartum cardiomyopathy or atrial fibrillation). Clinical manifestations and phenotypes of cardio-psycho-neurological diseases depend on the individual somatic, psychosocial, and genetic risk profile as well as on personal resilience, and differ in many respects between men and women. In this article, we provide arguments on why, in such conditions, multidisciplinary collaborations should be established to allow for more comprehensive understanding of the pathophysiology as well as appropriate and targeted diagnosis and treatment. In addition, we summarize current knowledge on the complex interactions between the cardiovascular and central nervous systems in Takotsubo syndrome and peripartum cardiomyopathy, and on the neurological and psychiatric complications of atrial fibrillation.

Neglected cardiovascular diseases and their significance in the Global North

Due to increasing global migration, the spectrum of cardiovascular disease (CVD) is changing in developed countries. Up to 3% of migrants arriving in Europe have underlying CVD. Despite their high global prevalence, conditions such as rheumatic heart disease, Chagas disease, endomyocardial fibrosis, tuberculous pericarditis, peripartum cardiomyopathy, and pulmonary hypertension are often under-recognized, and, as a result, neglected in industrialized countries. Many of these conditions, and their causes, are often unfamiliar to the health-care providers in host countries. In this review, we summarize the epidemiology, etiology, clinical presentation, diagnostic work-up, and management of neglected CVDs that have an increasing prevalence in the Global North.

Assessment of major mental disorders in a German peripartum cardiomyopathy cohort

AIMS

Peripartum cardiomyopathy (PPCM) is a heart disease affecting women during the last month of pregnancy or in the first months after delivery. The impact of the disease on mental health is largely unknown.

METHODS AND RESULTS

Major mental disorders were assessed by a structured clinical interview in 40 patients with a confirmed PPCM diagnosis, and the data were compared with published prevalence in postpartum women. Circulating biomarkers associated with mental health, such as kynurenine, serotonin, and microRNA (miR)-30e, were evaluated in PPCM and compared with matched healthy pregnancy-matched postpartum controls (PP-Ctrl). Major mental disorders were diagnosed in 65% (26/40) of the PPCM cohort. The prevalence for major depressive disorders was 4-fold, for post-traumatic stress disorder 14-fold, and for panic disorder 6-fold higher in PPCM patients compared with postpartum women without a PPCM diagnosis. Compared with PP-Ctrl, PPCM patients displayed elevated levels of serum kynurenine (P < 0.01), reduced levels of serum serotonin (P < 0.05), and elevated levels of plasma miR-30e (P < 0.05).

CONCLUSIONS

The majority of PPCM patients in the present cohort displayed mental disorders with a higher prevalence of major depressive disorders, post-traumatic stress disorder (PTBS), and panic disorder, compared with postpartum women without a PPCM diagnosis. This higher prevalence was associated with an impaired tryptophan metabolism and elevated levels of the depression-associated miR-30e, suggesting a potential predisposition for mental disorders at the time of PPCM diagnosis. Consequently, physicians should be aware of the increased risk for mental disorders in PPCM patients, and psychiatric assessment should be included in the diagnosis and management of PPCM patients.