Hypertensive Disorders of Pregnancy and Peripartum Cardiomyopathy: A Meta-Analysis of Prevalence and Impact on Left Ventricular Function and Mortality

Background: The purpose of this meta-analysis was to examine the prevalence of hypertensive disorders of pregnancy (HDPs), particularly preeclampsia (PE), in peripartum cardiomyopathy (PPCM)-affected pregnancies, and to evaluate whether a HDP significantly alters the prognosis of PPCM, with specific reference to the recovery of left ventricular function (LVEF) and mortality. Methods: A total of 5468 potentially eligible studies were identified, and 104 were included in the meta-analysis. For pooling proportions, the inverse variance methods with logit transformation were used. Complete recovery of LVEF (>50%) and mortality were expressed by odds ratios (ORs), with 95% confidence intervals (CIs). The Peto OR (POR) was used in cases of rare events. Baseline LV function and baseline LV end-diastolic diameter (LVEDD) were summarized by the mean difference (MD) and 95% confidence interval (CI). Results: The summary estimate of the prevalence of HDPs and PE in women with PPCM was 36% and 25%, respectively. Patients with HDPs and, more specifically, PE with PPCM had a higher chance of complete recovery (OR = 1.87; 95%CI = 1.64 to 2.13; p < 0.001 and OR = 1.98; 95%CI 1.69 to 2.32; p < 0.001, respectively), a higher baseline LVEF (MD, 1.42; 95% CI 0.16 to 2.67; p = 0.03 and MD, 1.69; 95% CI 0.21 to 3.18; p = 0.03, respectively), and a smaller baseline LVEDD (MD, -1.31; 95% CI -2.50 to -0.13; p = 0.03 and MD, -2.63; 95% CI -3.75 to -1.51; p < 0.001, respectively). These results, however, did not translate into a significant difference in 12-month mortality (POR = 0.80; 95% CI = 0.57 to 1.13; p = 0.21 and POR = 1.56; 95% CI 0.90 to 2.73; p = 0.12, respectively). Conclusions: The findings of this study may contribute to evidence that can be utilized to aid in the risk stratification of patients with PPCM regarding their long-term prognoses.

Outcomes of peripartum cardiomyopathy in North Africa: insights from a single-center observational study in Tunisia

BACKGROUND

Peripartum cardiomyopathy (PPCM) is a rare but potentially life-threatening condition. Due to the scarcity of epidemiological data in North Africa, we conducted this study to assess the outcomes of PPCM in our region.

MATERIALS AND METHODS

This monocentric retrospective cohort study involving all patients diagnosed with PPCM was conducted between January 2010 and December 2022.

RESULTS

Twenty-seven PPCM patients, with a median age of 33 years (Interquartile range (IQR) = 9), were included. 52% of patients were diagnosed during the postpartum period. Dyspnea New York Heart Association III/IV(NYHA III/IV) was the most common functional symptom (85%). The median left ventricle ejection fraction (LVEF) was 30% (IQR = 11%). Atrial fibrillation occurred in 11.1% of patients, thromboembolic complications occurred in 18.5%, Pulmonary edema occurred in 85% of patients and cardiogenic shock occurred in 14.8% of patients, with two patients requiring Extracorporeal Membrane Oxygenation (ECMO) support. The predominant mode of delivery was a cesarean Sect. (82% of patients), and the indication for a cesarean delivery was obstetrical in 59% of patients. Prematurity occurred in 36% of newborns, and intrauterine fetal death occurred in one pregnancy. The median follow-up was 24 months [6-144 months]. LVEF recovery was noted in 67% of patients. Bromocriptine was administered to six patients (22%), and none of these patients died and out of them, five patients recovered their LVEF (83%). The overall mortality rate during the follow-up period was 15%, comprising three in-hospital cardiac deaths and one occurring two years later due to refractory advanced heart failure. No significant differences were observed between LVEF recovery and LVEF non-recovery groups. Factors significantly associated with mortality were multiparity, poor antenatal care (ANC) attendance, thromboembolic events, cardiogenic shock, and Pulmonary edema. Five patients with LV recovery subsequently became pregnant, none experienced a relapse of PPCM. However, one of the descendants of a patient was diagnosed with dilated cardiomyopathy.

CONCLUSION

This study revealed that the diagnosis of PPCM in our hospital is often delayed until symptoms become more advanced, resulting in high morbi-mortality.

Recovery of left ventricular systolic function in peripartum cardiomyopathy: an observational study from rural Tanzania

BACKGROUND

The aim of this study was to evaluate the recovery rate of the left ventricular systolic function of women diagnosed with peripartum cardiomyopathy receiving specialized care in rural Tanzania.

METHODS

In this observational study, women diagnosed with peripartum cardiomyopathy at a referral center in rural Tanzania between December 2015 and September 2021 were included. Women diagnosed between February and September 2021 were followed prospectively, those diagnosed between December 2015 and January 2021 were tracked back for a follow-up echocardiography. All participants received a clinical examination, a comprehensive echocardiogram, and a prescription of guideline-directed medical therapy. The primary outcome was recovery of the left ventricular systolic function (left ventricular ejection fraction > 50%).

RESULTS

Median age of the 110 participants was 28.5 years (range 17-45). At enrolment, 49 (45%) participants were already on cardiac medication, 50 (45%) had severe eccentric hypertrophy of the left ventricle, and the median left ventricular ejection fraction was 30% (range 15-46). After a median follow-up of 8.98 months (IQR 5.72-29.37), 61 (55%) participants were still on cardiac medication. Full recovery of the left ventricular systolic function was diagnosed in 76 (69%, 95% CI 59.6-77.6%) participants. In the multivariate analysis, a higher left ventricular ejection fraction at baseline was positively associated with full recovery (each 5% increase; OR 1.7, 95% CI 1.10-2.62, p = 0.012), while higher age was inversely associated (each 10 years increase; OR 0.40, 95% CI 0.19-0.82, p = 0.012).

CONCLUSION

Left ventricular systolic function recovered completely in 69% of study participants with peripartum cardiomyopathy from rural Tanzania under specialized care.

Outcomes of subsequent pregnancy in women with peripartum cardiomyopathy: a systematic review and meta-analysis

INTRODUCTION

The primary concern for women who have experienced peripartum cardiomyopathy (PPCM) is the safety of a subsequent pregnancy (SSP). To maximie decision-making, facilitate effective patient counselling, and ultimately improve maternal and fetal outcomes as a whole, it is critical to comprehend the outcomes of SSP in women who have previously experienced PPCM. This study aimed to evaluate the outcomes of SSP in women with PPCM.

METHODS

Three databases (PubMed, Scopus, and ScienceDirect) were used to identify relevant studies prior to 17 October 2023. A total of 662 studies were reviewed. Following the abstract and full-text screenings, 18 observational studies were included, out of which 2 were deemed suitable for inclusion in this meta-analysis. The quality assessment was conducted using the Newcastle-Ottawa Scale.

RESULTS

This study has a total of 487 SSPs. Although recovered left ventricular (LV) function before entering SSP has the potential to be a beneficial prognostic factor, recovered LV function still has a substantial risk of relapse. The mortality rate of PPCM in an SSP ranged from 0% to 55.5%. Persistent LV dysfunction was significantly associated with an increased mortality rate (OR 13.17; 95% CI 1.54 to 112.28; p=0.02) and lower LV ejection fraction (MD -12.88; 95% CI -21.67 to -4.09; p=0.004). Diastolic and right ventricular functions remained unchanged before SSP and at follow-up. The majority of the SSP was observed alongside hypertension, while pre-eclampsia emerged as the predominant hypertensive complication in most studies.

CONCLUSION

SSP increases the risk of relapse and mortality in women with a previous history of PPCM. Persistent LV dysfunction prior to the SSP has a higher mortality risk compared with recovered LV function. SSP was also associated with the worsening of LV echocardiography parameters.

Peripartum cardiomyopathy in low- and middle-income countries

Peripartum cardiomyopathy (PPCM) causes pregnancy-associated heart failure, typically during the last month of pregnancy, and up to 6 months post-partum, in women without known cardiovascular disease. PPCM is a global disease, but with a significant geographical variability within and between countries. Its true incidence in Africa is still unknown because of the lack of a PPCM population-based study. The variability in the epidemiology of PPCM between and within countries could be due to differences in the prevalence of both genetic and non-genetic risk factors. Several risk factors have been implicated in the aetiopathogenesis of PPCM over the years. Majority of patients with PPCM present with symptoms and signs of congestive cardiac failure. Diagnostic work up in PPCM is prompted by strong clinical suspicion, but Echocardiography is the main imaging technique for diagnosis. The management of PPCM involves multiple disciplines - cardiologists, anaesthetists, intensivists, obstetricians, neonatologists, and the prognosis varies widely.

Outcomes at one year in women with peripartum cardiomyopathy: Findings from the ESC EORP PPCM Registry

AIMS

There are few prospective reports of 1-year outcomes for women with peripartum cardiomyopathy (PPCM). We report findings from the European Society of Cardiology EURObservational Research Programme PPCM Registry.

METHODS AND RESULTS

The registry enrolled women from 51 countries from 2012 to 2018. Eligibility included: (i) a peripartum state, (ii) signs or symptoms of heart failure, (iii) left ventricular (LV) ejection fraction ≤45%, (iv) exclusion of alternative causes of heart failure. We report mortality, thromboembolism, stroke, rehospitalization, LV recovery and remodelling at 1 year. Differences between regions were compared. One-year mortality data were available in 535 (71%) women and follow-up differed across regions. At 1 year, death from any cause occurred in 8.4% of women, with regional variation (Europe 4.9%, Africa 6.5%, Asia-Pacific 9.2%, Middle East 18.9%; p < 0.001). The frequencies of thromboembolism and stroke were 6.3% and 2.5%, respectively, and were similar across regions. A total of 14.0% of women had at least one rehospitalization and 3.5% had recurrent rehospitalizations (i.e. two or more). Overall, 66.1% of women had recovery of LV function (22% between 6 months and 1 year), with a mean LV ejection fraction increase from baseline of 21.2% (±13.6). Recovery occurred most frequently in Asia-Pacific (77.5%) and least frequently in the Middle East (32.7%). There were significant regional differences in the use of heart failure pharmacotherapies.

CONCLUSIONS

Approximately 1 in 12 women with PPCM had died by 1 year and thromboembolism and stroke occurred in 6.3% and 2.5%, respectively. Around 1 in 7 women had been rehospitalized and, in 1 in 3, LV recovery had not occurred. PPCM is associated with substantial mortality and morbidity globally.

A 20-year population study of peripartum cardiomyopathy

BACKGROUND AND AIMS

The epidemiology of peripartum cardiomyopathy (PPCM) in Europe is poorly understood and data on long-term outcomes are lacking. A retrospective, observational, population-level study of validated cases of PPCM in Scotland from 1998 to 2017 was conducted.

METHODS

Women hospitalized with presumed de novo left ventricular systolic dysfunction around the time of pregnancy and no clear alternative cause were included. Each case was matched to 10 controls. Incidence and risk factors were identified. Morbidity and mortality were examined in mothers and children.

RESULTS

The incidence of PPCM was 1 in 4950 deliveries. Among 225 women with PPCM, obesity, gestational hypertensive disorders, and multi-gestation were found to be associated with having the condition. Over a median of 8.3 years (9.7 years for echocardiographic outcomes), 8% of women with PPCM died and 75% were rehospitalized for any cause at least once. Mortality and rehospitalization rates in women with PPCM were ∼12- and ∼3-times that of controls, respectively. The composite of all-cause death, mechanical circulatory support, or cardiac transplantation occurred in 14%. LV recovery occurred in 76% and, of those who recovered, 13% went on to have a decline in LV systolic function despite initial recovery. The mortality rate for children born to women with PPCM was ∼5-times that of children born to controls and they had an ∼3-times greater incidence of cardiovascular disease over a median of 8.8 years.

CONCLUSIONS

PPCM affected 1 in 4950 women around the time of pregnancy. The condition is associated with considerable morbidity and mortality for the mother and child. There should be a low threshold for investigating at-risk women. Long term follow-up, despite apparent recovery, should be considered.

Culture, ethnicity, and socio-economic status as determinants of the management of patients with advanced heart failure who need palliative care: A clinical consensus statement from the Heart Failure Association (HFA) of the ESC, the ESC Patient Forum, and the European Association of Palliative Care

The delivery of effective healthcare entails the configuration and resourcing of health economies to address the burden of disease, including acute and chronic heart failure, that affects local populations. Increasing migration is leading to more multicultural and ethnically diverse societies worldwide, with migration research suggesting that minority populations are often subject to discrimination, socio-economic disadvantage, and inequity of access to optimal clinical support. Within these contexts, the provision of person-centred care requires medical and nursing staff to be aware of and become adept in navigating the nuances of cultural diversity, and how that can impact some individuals and families entrusted to their care. This paper will examine current evidence, provide practical guidance, and signpost professionals on developing cultural competence within the setting of patients with advanced heart failure who may benefit from palliative care.

Korean Society of Heart Failure Guidelines for the Management of Heart Failure: Management of the Underlying Etiologies and Comorbidities of Heart Failure

Most patients with heart failure (HF) have multiple comorbidities, which impact their quality of life, aggravate HF, and increase mortality. Cardiovascular comorbidities include systemic and pulmonary hypertension, ischemic and valvular heart diseases, and atrial fibrillation. Non-cardiovascular comorbidities include diabetes mellitus (DM), chronic kidney and pulmonary diseases, iron deficiency and anemia, and sleep apnea. In patients with HF with hypertension and left ventricular hypertrophy, renin-angiotensin system inhibitors combined with calcium channel blockers and/or diuretics is an effective treatment regimen. Measurement of pulmonary vascular resistance via right heart catheterization is recommended for patients with HF considered suitable for implantation of mechanical circulatory support devices or as heart transplantation candidates. Coronary angiography remains the gold standard for the diagnosis and reperfusion in patients with HF and angina pectoris refractory to antianginal medications. In patients with HF and atrial fibrillation, long-term anticoagulants are recommended according to the CHA2DS2-VASc scores. Valvular heart diseases should be treated medically and/or surgically. In patients with HF and DM, metformin is relatively safer; thiazolidinediones cause fluid retention and should be avoided in patients with HF and dyspnea. In renal insufficiency, both volume status and cardiac performance are important for therapy guidance. In patients with HF and pulmonary disease, beta-blockers are underused, which may be related to increased mortality. In patients with HF and anemia, iron supplementation can help improve symptoms. In obstructive sleep apnea, continuous positive airway pressure therapy helps avoid severe nocturnal hypoxia. Appropriate management of comorbidities is important for improving clinical outcomes in patients with HF.

Korean Society of Heart Failure Guidelines for the Management of Heart Failure: Management of the Underlying Etiologies and Comorbidities of Heart Failure

Most patients with heart failure (HF) have multiple comorbidities, which impact their quality of life, aggravate HF, and increase mortality. Cardiovascular comorbidities include systemic and pulmonary hypertension, ischemic and valvular heart diseases, and atrial fibrillation. Non-cardiovascular comorbidities include diabetes mellitus (DM), chronic kidney and pulmonary diseases, iron deficiency and anemia, and sleep apnea. In patients with HF with hypertension and left ventricular hypertrophy, renin-angiotensin system inhibitors combined with calcium channel blockers and/or diuretics is an effective treatment regimen. Measurement of pulmonary vascular resistance via right heart catheterization is recommended for patients with HF considered suitable for implantation of mechanical circulatory support devices or as heart transplantation candidates. Coronary angiography remains the gold standard for the diagnosis and reperfusion in patients with HF and angina pectoris refractory to antianginal medications. In patients with HF and atrial fibrillation, long-term anticoagulants are recommended according to the CHA2DS2-VASc scores. Valvular heart diseases should be treated medically and/or surgically. In patients with HF and DM, metformin is relatively safer; thiazolidinediones cause fluid retention and should be avoided in patients with HF and dyspnea. In renal insufficiency, both volume status and cardiac performance are important for therapy guidance. In patients with HF and pulmonary disease, beta-blockers are underused, which may be related to increased mortality. In patients with HF and anemia, iron supplementation can help improve symptoms. In obstructive sleep apnea, continuous positive airway pressure therapy helps avoid severe nocturnal hypoxia. Appropriate management of comorbidities is important for improving clinical outcomes in patients with HF.

Transcriptomic Comparison of Human Peripartum and Dilated Cardiomyopathy Identifies Differences in Key Disease Pathways

Peripartum cardiomyopathy (PPCM) is a rare form of acute onset heart failure that presents in otherwise healthy pregnant women around the time of delivery. While most of these women respond to early intervention, about 20% progress to end-stage heart failure that symptomatically resembles dilated cardiomyopathy (DCM). In this study, we examined two independent RNAseq datasets from the left ventricle of end-stage PPCM patients and compared gene expression profiles to female DCM and non-failing donors. Differential gene expression, enrichment analysis and cellular deconvolution were performed to identify key processes in disease pathology. PPCM and DCM display similar enrichment in metabolic pathways and extracellular matrix remodeling suggesting these are similar processes across end-stage systolic heart failure. Genes involved in golgi vesicles biogenesis and budding were enriched in PPCM left ventricles compared to healthy donors but were not found in DCM. Furthermore, changes in immune cell populations are evident in PPCM but to a lesser extent compared to DCM, where the latter is associated with pronounced pro-inflammatory and cytotoxic T cell activity. This study reveals several pathways that are common to end-stage heart failure but also identifies potential targets of disease that may be unique to PPCM and DCM.

Prognostic Value of Cardiac MRI Late Gadolinium Enhancement in Patients with Peripartum Cardiomyopathy: A Retrospective Study

A significant proportion of peripartum cardiomyopathy (PPCM) patients experience persistent heart failure even death, the underneath reason of non-recovery may attribute to the myocardial tissue damage. This study aims to explore the prognostic value of cardiac MRI late gadolinium enhancement (LGE) in women with PPCM, and further establish a predictive model for poor outcomes. Eighty-four consecutively diagnosed women with PPCM underwent cardiac MRI between January 2010 to December 2019. A combined endpoint of poor outcomes (death, New York Heart Association functional class III/IV, heart transplantation or a persistently reduced left ventricular ejection fraction [LVEF)] and complete recovery [an LVEF ≥50%]) were defined. Least absolute shrinkage and selection operator regression and nomogram model were performed to demonstrate prognostic value of cardiac MRI. Higher occurrence of LGE was detected in PPCM women with reached poor outcomes than those who completely recovered (odds ratio: 4.4, 95% CI: 2.6 to 7.5, P<0.001) . PPCM women with LGE+ were more likely to reach combined endpoint of poor outcomes than those with LGE- (odds ratio: 8.2, 95% CI: 1.1 to 59.2, P=0.003). The poor outcome-free rates PPCM women in the group with LGE were lower than those without LGE (log-rank χ2=13.5, P<0.001). LGE presence (hazard ratio [HR]=10.7, 95% CI: 1.38-83.5, P<0.05) and LGE extent (HR=1.2, 95% CI: 1.0-1.3, P<0.05) were prognostic factors for poor outcomes. The predictive nomogram model on LGE showed good discrimination (C index=0.8, 95% CI: 0.6-0.9).Cardiac MRI LGE was an incremental predictive modality for poor outcomes and risk stratification in women with PPCM.

Meta-Analysis of Long-Term (>1 Year) Cardiac Outcomes of Peripartum Cardiomyopathy

Peripartum cardiomyopathy is the development of heart failure toward the end of pregnancy or in the months after delivery in the absence of other attributable causes, with left ventricular systolic dysfunction and a left ventricular ejection fraction (LVEF) generally <45%. Given that patients are relatively young at the time of diagnosis, this study was performed to summarize current evidence surrounding the long-term cardiac outcomes. MEDLINE, Embase, Cochrane CENTRAL, and CINAHL were searched for original studies that reported long-term (>1 year) patient outcomes. Of the 3,144 total records identified, 62 studies involving 4,282 patients met the selection criteria. The mean LVEF was 28% at diagnosis and 47% at the time of the last follow-up. Approximately half of the patients achieved myocardial recovery (47%), most commonly defined as an LVEF >50% (n = 21). The prevalence of implantable cardioverter-defibrillator use, left ventricular assist device implantation, and heart transplantation was 12%, 7%, and 11%, respectively. The overall all-cause mortality was 9%, and despite having more cardiovascular risk factors, patients residing in high-income countries had superior outcomes, including reduced rates of mortality.

Clinical characteristics, predictors and pregnancy outcomes in Indian women with peripartum cardiomyopathy

BACKGROUND

Predictors, pregnancy and subsequent pregnancy outcomes in women with peripartum cardiomyopathy (PPCM) are poorly understood in our geographical region.

METHODS

We retrospectively analysed 58 women with PPCM diagnosed using criteria by the European Society of Cardiology during 2015 to 2019. The main outcome measures were predictors of left ventricular (LV) recovery. LV recovery was defined as return of LV ejection fraction to over 50%.

RESULTS

Nearly 80% of women had LV recovery during 6 months follow up. Univariate logistic regression revealed LV end diastolic diameter (adjusted odds ratio (OR); 0.87; 95% CI, 0.78-0.98; p = 0.02), LV end systolic diameter (OR; 0.89; 95% CI, 0.8-0.98; p = 0.02) and inotrope use (OR; 0.2, 95% CI, 0.05-0.7; p = 0.01) as predictors of LV recovery. Relapse was not seen in any of the nine women who had a subsequent pregnancy.

CONCLUSION

LV recovery was higher than those reported in contemporary PPCM cohorts from other parts of the world.

Clinical characteristics and long-term outcomes in patients with peripartum cardiomyopathy (PPCM) receiving left ventricular assist devices (LVAD)

BACKGROUND

Peripartum cardiomyopathy (PPCM) is a rare cause of heart failure (HF), presenting with left ventricular (LV) systolic dysfunction either at the end of pregnancy or in the months following delivery. In rare cases, PPCM leads to severe impairment of LV function, refractory cardiogenic shock or advanced HF. LV assist devices (LVAD) have been shown to be a feasible treatment option in advanced HF. However, little is known about long-term outcomes and prognosis of PPCM patients undergoing LVAD implantation.

METHODS

A retrospective analysis of data from PPCM patients undergoing LVAD implantation in two tertiary centers with respect to long-term outcomes was performed.

RESULTS

Twelve patients of median age 30 (18-39) years were included. Eight patients were experiencing cardiogenic shock (INTERMACS 1) at implantation. Seven patients were implanted within 1 month of their PPCM diagnosis. Median duration of LVAD support was 19 (2-92) months with median follow up of 67 (18-136) months (100% complete). In-hospital and 1-year mortality were 0% and 8.3%, respectively. Two patients died on LVAD support, four patients were successfully bridged to transplantation, two patients are still on LVAD, and four were successfully weaned due to sufficient LV recovery (one died after LV function deteriorated again).

CONCLUSION

LVAD treatment of decompensated end-stage PPCM is feasible. Early LVAD provision led to hemodynamic stabilization in our cohort and facilitated safe LV recovery in one third of these young female patients.

[Peripartum Cardiomyopathy]

Peripartum cardiomyopathy (PPCM) is a rare but potentially life-threatening heart disease, with onset in the last month of pregnancy or in the first months after delivery in previously heart-healthy women. PPCM patients typically present with heart failure due to left ventricular (LV) dysfunction with an LV ejection fraction (EF) < 45 %. In the last years clinical and experimental studies contributed to a better understanding of the pathophysiology and the clinical course of PPCM. In the context of oxidative stress, the nursing hormone prolactin is cleaved into a smaller antiangiogenic and proapoptotic 16k Da form, leading to myocardial dysfunction. In an animal model this can be prevented by treatment with the dopamine agonist bromocriptine, which suppresses prolactin release. This therapeutic approach was confirmed in several clinical studies. Therefore, the current guidelines recommend a treatment consisting of a heart failure treatment according to current guidelines in combination with the dopamine agonist bromocriptine. If the diagnosis is made early and the treatment is started immediately, the prognosis is good compared to other forms of cardiomyopathies, as LV function recovers in most cases.In the acute phase the severity of heart failure differs among PPCM patients. Some patients present with mild forms, whereas some PPCM patients display severely reduced LV function and cardiogenic shock. Especially the latter cases are still challenging, as treatment with β1-adrenergic receptor agonists is associated with progression of heart failure and a worse cardiac outcome. Therefore, patients with cardiogenic shock complicating PPCM should be treated in centers experienced in mechanical circulatory support in combination with bromocriptine treatment.

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.

Risk factors for intracardiac thrombus in peripartum cardiomyopathy: a retrospective study in China

AIMS

Peripartum cardiomyopathy (PPCM) are more vulnerable to intracardiac thrombus than other types of cardiomyopathies, although explicit anticoagulant strategy is not sure. Too aggressive anticoagulation therapy can lead to severe bleeding events. Hence, we want to construct a risk stratification model for intracardiac thrombus in PPCM patients.

METHODS AND RESULTS

A total of 159 suspected PPCM cases were initially screened, whereas 123 confirmed cases were enrolled in the final analysis. The study population was randomly assigned as derivation group (N = 83) and validation group (N = 40). The derivation cohort was utilized to develop the model, and the validation cohort was used to internal validate the discriminatory ability of the model. Formation of intracardiac thrombus was detected in 22 patients. After adjusted by multivariable logistic regression analysis, left ventricle ejection fraction (LVEF, OR 0.772, 95% CI 0.665-0.897, P = 0.001), haemoglobin levels (OR 1.050, 95% CI 1.003-1.099, P = 0.038), and thrombocyte counts (OR 1.018, 95% CI 1.006-1.029, P = 0.003) were identified as risk factors independently associated with intracardiac thrombus and were finally included in the tentative risk stratification model with a C-indexes of 0.916 (95% CI: 0.850-0.982, P < 0.001). A score of ≤7 was regarded as low risk, 8-10 defined intermediate risk, and ≥11 defined high risk in our model. Internal validation showed good discriminatory ability of the model with a C-indexes of 0.790 (95% CI: 0.644-0.936, P = 0.017).

CONCLUSIONS

In our retrospective study, impaired LVEF, elevated haemoglobin levels, and high thrombocyte counts were regarded as independent risk factors for intracardiac thrombus in PPCM. A risk stratification model derived from these risk factors, which was economic and easily applicable in clinical practice, could rapidly and accurately identify PPCM patients with higher-risk of intracardiac thrombus.

A global perspective on the management and outcomes of peripartum cardiomyopathy: a systematic review and meta-analysis

AIMS

Peripartum cardiomyopathy (PPCM) remains a major contributor to maternal morbidity and mortality worldwide. The disease is associated with various complications occurring mainly early during its course. Reported adverse outcomes include decompensated heart failure, thromboembolic complications, arrhythmias and death. We sought to systematically and comprehensively review published literature on the management, and outcome of women with PPCM across different geographical regions and to identify possible predictors of adverse outcomes.

METHODS AND RESULTS

We performed a comprehensive search of relevant literature (2000 to June 2021) across a number of electronic databases. Cohort, case-control and cross-sectional studies, as well as control arms of randomised controlled trials reporting on six- and/or twelve-month outcomes of PPCM were considered eligible (PROSPERO registration: CRD42021255654). Forty-seven studies (4875 patients across 60 countries) met the inclusion criteria. Haemodynamic and echocardiographic parameters were similar across all continents. All-cause mortality was 8.0% [95% CI 5.5-10.8, I² =79.1%) at six months and 9.8% [95% CI 6.2-14.0], I² =80.5%) at twelve months, respectively. All-cause mortality was highest in Africa and Asia/Pacific. Overall, 44.1% ([95% CI 36.1-52.2], I² =91.7%) of patients recovered their LV function within six months and 58.7% ([95% CI 48.1-68.9], I² =75.8%) within twelve months, respectively. Europe and North America reported the highest prevalence of LV recovery. Frequent prescription of beta-blocker, ACE-I/ARB and bromocriptine/cabergoline were associated with significantly lower all-cause mortality and better LV recovery.

CONCLUSION

We identified significant global differences in six- and twelve-month outcomes in women with PPCM. Frequent prescription of guideline-directed heart failure therapy was associated with better LV recovery and lower all-cause mortality. Timely initiation and up-titration of heart failure therapy should therefore be strongly encouraged to improve outcome in PPCM. This article is protected by copyright. All rights reserved.

Using Echocardiography and Biomarkers to Determine Prognosis in Peripartum Cardiomyopathy: A Systematic Review

Peripartum cardiomyopathy (PPCM) is a rare but debilitating form of heart failure that affects pregnant women. Although PPCM has a high rate of complete resolution, some patients often have a progressive disease and develop significant morbidity and mortality. Making an accurate prediction of outcomes and identifying those patients at the highest risk has proven difficult over the years. This study aimed to establish if we can use echocardiographic parameters and biomarkers as reliable indicators of prognosis. A predetermined systematic search strategy was employed in four databases: PubMed, Google Scholar, Science Direct, and Cochrane Library to include articles from the last 15 years (January 2007 to January 2022). Data from 12 studies were synthesized and included in this study. Although no parameter proved consistent in all the studies, echocardiographic parameters, including strain profiles and biomarkers, proved significant in the prognostication of patients with PPCM in the various studies evaluated. Therefore, a holistic approach is still needed in the risk stratification of patients with PPCM. Future studies should evaluate these parameters as well as clinical characteristics in a larger cohort study with a long follow-up period of more than one year in order to potentially develop prognostic score criteria that can be used to accurately identify those patients at the highest risk of developing severe disease or death to allow for timely and targeted therapies to improve outcomes in these patients.

2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.

METHODS

A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. Structure: Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure

AIM

The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.

METHODS

A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021.

STRUCTURE

Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: Developed by the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). With the special contribution of the Heart Failure Association (HFA) of the ESC

Document Reviewers: Rudolf A. de Boer (CPG Review Coordinator) (Netherlands), P. Christian Schulze (CPG Review Coordinator) (Germany), Magdy Abdelhamid (Egypt), Victor Aboyans (France), Stamatis Adamopoulos (Greece), Stefan D. Anker (Germany), Elena Arbelo (Spain), Riccardo Asteggiano (Italy), Johann Bauersachs (Germany), Antoni Bayes-Genis (Spain), Michael A. Borger (Germany), Werner Budts (Belgium), Maja Cikes (Croatia), Kevin Damman (Netherlands), Victoria Delgado (Netherlands), Paul Dendale (Belgium), Polychronis Dilaveris (Greece), Heinz Drexel (Austria), Justin Ezekowitz (Canada), Volkmar Falk (Germany), Laurent Fauchier (France), Gerasimos Filippatos (Greece), Alan Fraser (United Kingdom), Norbert Frey (Germany), Chris P. Gale (United Kingdom), Finn Gustafsson (Denmark), Julie Harris (United Kingdom), Bernard Iung (France), Stefan Janssens (Belgium), Mariell Jessup (United States of America), Aleksandra Konradi (Russia), Dipak Kotecha (United Kingdom), Ekaterini Lambrinou (Cyprus), Patrizio Lancellotti (Belgium), Ulf Landmesser (Germany), Christophe Leclercq (France), Basil S. Lewis (Israel), Francisco Leyva (United Kingdom), AleVs Linhart (Czech Republic), Maja-Lisa Løchen (Norway), Lars H. Lund (Sweden), Donna Mancini (United States of America), Josep Masip (Spain), Davor Milicic (Croatia), Christian Mueller (Switzerland), Holger Nef (Germany), Jens-Cosedis Nielsen (Denmark), Lis Neubeck (United Kingdom), Michel Noutsias (Germany), Steffen E. Petersen (United Kingdom), Anna Sonia Petronio (Italy), Piotr Ponikowski (Poland), Eva Prescott (Denmark), Amina Rakisheva (Kazakhstan), Dimitrios J. Richter (Greece), Evgeny Schlyakhto (Russia), Petar Seferovic (Serbia), Michele Senni (Italy), Marta Sitges (Spain), Miguel Sousa-Uva (Portugal), Carlo G. Tocchetti (Italy), Rhian M. Touyz (United Kingdom), Carsten Tschoepe (Germany), Johannes Waltenberger (Germany/Switzerland) All experts involved in the development of these guidelines have submitted declarations of interest. These have been compiled in a report and published in a supplementary document simultaneously to the guidelines. The report is also available on the ESC website www.escardio.org/guidelines For the Supplementary Data which include background information and detailed discussion of the data that have provided the basis for the guidelines see European Heart Journal online.

Pathophysiology and risk factors of peripartum cardiomyopathy

Peripartum cardiomyopathy (PPCM) is a potentially fatal form of idiopathic heart failure with variable prevalence across different countries and ethnic groups. The cause of PPCM is unclear, but environmental and genetic factors and pregnancy-associated conditions such as pre-eclampsia can contribute to the development of PPCM. Furthermore, animal studies have shown that impaired vascular and metabolic function might be central to the development of PPCM. A better understanding of the pathogenic mechanisms involved in the development of PPCM is necessary to establish new therapies that can improve the outcomes of patients with PPCM. Pregnancy hormones tightly regulate a plethora of maternal adaptive responses, including haemodynamic, structural and metabolic changes in the cardiovascular system. In patients with PPCM, the peripartum period is associated with profound and rapid hormonal fluctuations that result in a brief period of disrupted cardiovascular (metabolic) homeostasis prone to secondary perturbations. In this Review, we discuss the latest studies on the potential pathophysiological mechanisms of and risk factors for PPCM, with a focus on maternal cardiovascular changes associated with pregnancy. We provide an updated framework to further our understanding of PPCM pathogenesis, which might lead to an improvement in disease definition.

Effects of bromocriptine in peripartum cardiomyopathy: a systematic review and meta-analysis

Peripartum cardiomyopathy (PPCM) is a rare but potentially life-threatening form of heart failure (HF). Bromocriptine, a dopamine D2 agonist, has been used as an adjunctive treatment for PPCM with controversial benefits. A comprehensive literature search was conducted through June 2021. We included studies comparing the outcomes of PPCM with or without bromocriptine use. Pooled risk ratio (RR) with 95% confidence intervals (CI) and I² statistics were calculated. Composite major adverse outcomes were defined by a composite of death, need for advanced HF therapies, persistent New York Heart Association (NYHA) functional class III/V, or left ventricular ejection fraction (LVEF) ≤ 35% at 6-month follow-up. LVEF recovery was defined by improvement of LVEF to more than 50%. Eight studies (two randomized-controlled, six observational) involving 593 PPCM patients were included. Bromocriptine use was associated with significantly higher survival (91.6% vs. 83.9%, RR 1.11 p = 0.02). Baseline LVEF was not significantly different between the groups. LVEF at follow-up was significantly higher in the bromocriptine group (53.3% vs. 41.8%, p < 0.001). There was no significant association between bromocriptine use and lower composite major adverse outcomes (13.7% vs. 33.3%, RR 0.60 p = 0.54) or LVEF recovery (46.9% vs. 46.8%, RR 0.94 p = 0.74). In conclusion, the addition of bromocriptine to standard HF treatment in PPCM was associated with significantly higher survival and higher LVEF improvement. No association with lower composite adverse clinical outcomes or LVEF recovery was seen. The findings, although encouraging, warrant larger randomized-controlled studies.

Peripartum Cardiomyopathy

Peripartum cardiomyopathy (PPCM) is a form of heart failure that occurs toward the end of pregnancy or in the months following pregnancy and is marked by left ventricular systolic dysfunction. The cause of PPCM remains unknown and there is no diagnostic test specific to PPCM. Outcomes vary and include complete left ventricular recovery, persistent cardiac dysfunction, transplant, and death. Numerous advances have been made in understanding this disease, but many knowledge gaps remain. This article reviews recent data and recommendations for clinical practice in addition to highlighting the multiple knowledge gaps related to PPCM that warrant further investigation.

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.

Peripartum cardiomyopathy

Peripartum cardiomyopathy is now increasingly recognized as a cause of heart failure in the later months of pregnancy and early postpartum period. Clinical diagnosis may be challenging as it closely resembles several common medical and obstetric complications. Complex pathogenesis, unpredictable onset, staggered recovery, and unanticipated fetomaternal risks pose unique challenge to clinicians. Prevalence seems to vary with race, geographic location, and diagnostic criteria. The presence of multiple risk factors substantially elevates the risk of PPCM. Transthoracic echocardiographic examination can exclude the majority of the mimickers. Symptomatic presentation is initially limited to, varying grades of low cardiac output syndrome. Rarely, PPCM begins with decompensated heart failure and cardiovascular collapse. Guideline-directed medical therapy involves graded initiation and titration of heart failure medications while ensuring the fetal and neonatal safety. Anesthetic and obstetric management should be individualized to improve fetomaternal outcomes. However, emergent cesarean delivery may be required in women with decompensated heart failure and cardiovascular collapse. An early institution of mechanical circulatory support has shown to improve outcome. Bromocriptine and other experimental drugs designed to target pathogenic pathway have yielded mixed results. A further change in approach to management requires a comprehensive understanding of pathophysiology and fetomaternal safety profiles of heart failure medications.

Disparities in clinical features and outcomes of peripartum cardiomyopathy in high versus low prevalent regions in Nigeria

Aims

The prospective, multicentre Peripartum Cardiomyopathy in Nigeria (PEACE) registry originally demonstrated a high prevalence of peripartum cardiomyopathy (PPCM) among patients originating from Kano, North‐West Nigeria. In a post hoc analysis, we sought to determine if this phenomenon was characterized by a differential case profile and outcome among PPCM cases originating elsewhere.

Methods and results

Overall, 199 (81.6%) of a total 244 PPCM patients were recruited from three sites in Kano, compared with 45 patients (18.4%) from 11 widely dispersed centres across Nigeria. Presence and extent of ventricular myocardial remodelling during follow‐up, relative to baseline status, were assessed by echocardiography. During median 17 months follow‐up, Kano patients demonstrated significantly better myocardial reverse remodelling than patients from other sites. Overall, 50.6% of patients from Kano versus 28.6% from other regions were asymptomatic (P = 0.029) at study completion, with an accompanying difference in all‐cause mortality (17.6% vs. 22.2% respectively, P = 0.523) not reaching statistical significance. Alternatively, 135/191 (84.9%) of Kano patients had selenium deficiency (<70 μg/L), and 46/135 (34.1%) of them received oral selenium supplementation. Critically, those that received selenium supplementation demonstrated better survival (6.5% vs. 21.2%; P = 0.025), but the supplement did not have significant impact on myocardial remodelling.

Conclusions

This study has shown important non‐racial regional disparities in the clinical features and outcomes of PPCM patients in Nigeria, that might partly be explained by selenium supplementation.

Hypertensive disorders in women with peripartum cardiomyopathy: insights from the ESC Peripartum Cardiomyopathy Registry

Aims

Hypertensive disorders occur in women with peripartum cardiomyopathy (PPCM). How often hypertensive disorders co‐exist, and to what extent they impact outcomes, is less clear. We describe differences in phenotype and outcomes in women with PPCM with and without hypertensive disorders during pregnancy.

Methods and results

The European Society of Cardiology EURObservational Research Programme PPCM Registry enrolled women with PPCM from 2012–2018. Three groups were examined: (i) women without hypertension (PPCM‐noHTN); (ii) women with hypertension but without pre‐eclampsia (PPCM‐HTN); (iii) women with pre‐eclampsia (PPCM‐PE). Maternal (6‐month) and neonatal outcomes were compared. Of 735 women included, 452 (61.5%) had PPCM‐noHTN, 99 (13.5%) had PPCM‐HTN and 184 (25.0%) had PPCM‐PE. Compared to women with PPCM‐noHTN, women with PPCM‐PE had more severe symptoms (New York Heart Association class IV in 44.4% vs. 29.9%, P < 0.001), more frequent signs of heart failure (pulmonary rales in 70.7% vs. 55.4%, P = 0.002), a higher baseline left ventricular ejection fraction (LVEF) (32.7% vs. 30.7%, P = 0.005) and a smaller left ventricular end‐diastolic diameter (57.4 ± 6.7 mm vs. 59.8 ± 8.1 mm, P = 0.001). There were no differences in the frequencies of death from any cause, rehospitalization for any cause, stroke, or thromboembolic events. Compared to women with PPCM‐noHTN, women with PPCM‐PE had a greater likelihood of left ventricular recovery (LVEF ≥ 50%) (adjusted odds ratio 2.08, 95% confidence interval 1.21–3.57) and an adverse neonatal outcome (composite of termination, miscarriage, low birth weight or neonatal death) (adjusted odds ratio 2.84, 95% confidence interval 1.66–4.87).

Conclusion

Differences exist in phenotype, recovery of cardiac function and neonatal outcomes according to hypertensive status in women with PPCM.

Perhexiline treatment improves toxic effects of β-adrenergic receptor stimulation in experimental peripartum cardiomyopathy

Aims

Peripartum cardiomyopathy (PPCM) is a pregnancy‐associated cardiomyopathy that occurs in previously heart‐healthy women towards the end of pregnancy or in the first months after delivery and is characterized by heart failure due to systolic dysfunction. The clinical course of PPCM differs between mild symptoms and severe forms with acute heart failure complicated by cardiogenic shock (CS). Treatment of CS complicating PPCM is challenging, as β‐adrenergic receptor (β‐AR) stimulation seems to be associated with progression of heart failure and adverse outcome. This experimental study aims to examine whether postpartum treatment with the glucose uptake‐promoting drug perhexiline alone or as co‐treatment with β‐AR stimulation prevents heart failure in the experimental PPCM mouse model.

Methods and results

Postpartum (PP) female PPCM‐prone mice with a cardiomyocyte‐restricted STAT3‐deficiency (αMHC‐Cre^tg/+;Stat3^fl/fl; CKO) were treated with perhexiline over two to three pregnancies and nursing periods (2/3PP) or were co‐treated with perhexiline after one pregnancy (1PP) under chronic β‐AR stimulation using isoproterenol (Iso) infusion. Perhexiline was not able to prevent onset of PPCM in CKO mice (FS: CKO Pexsig‐2/3PP: 25 ± 12% vs. CKO Ctrl‐2/3PP: 24 ± 9%, n.s.) but attenuated worsening of left ventricular function in response to treatment with the β‐AR agonist Iso (FS: CKO Pexsig‐Iso‐1PP: 19 ± 4% vs. CKO Ctrl‐Iso‐1PP: 11 ± 5%, P < 0.05).

Conclusions

Treatment of PPCM patients with β‐AR agonists should be avoided whenever possible. In cases with CS complicating PPCM, when treatment with β‐AR agonists cannot be prevented, co‐medication with perhexiline might help to reduce the cardiotoxic side effects of β‐AR stimulation. Clinical data are necessary to further validate this therapeutic approach.

Cardiovascular adverse events in pregnancy: A global perspective

Pregnant women with heart disease are vulnerable to many adverse cardiovascular events (AE). AEs during and after pregnancy continue to be important causes of maternal mortality and morbidity worldwide, with huge variations in burden in different countries and regions. These AEs are classified as having direct or indirect causes, depending on whether they are directly caused by pregnancy or due to some pre-existing disease and/or non-obstetric cause, respectively. The risks continue throughout pregnancy and even after childbirth. Apart from immediate complications during pregnancy, there is increasing evidence of a significant link between several events and the risk of cardiovascular disease (CVD) later in life. A significant number of pregnancy-related deaths caused by cardiovascular disease are preventable. This prevention can be realized through increasing awareness of cardiovascular AE in pregnancy, coupled with the application of strategies for prevention and treatment. Knowledge of the risks associated with CVD and pregnancy is of extreme importance in that regard. We discuss the global distribution of cardiovascular maternal mortality, adverse events during and after pregnancy, their predictors and risk stratification. In addition, we enumerate possible solutions, particularly the role of cardio-obstetric clinics.

Acute kidney injury predicts poor left ventricular function for patients with peripartum cardiomyopathy

Background

The aim of this study was to explore the risk factors associated with a poor left ventricular (LV) function among patients with peripartum cardiomyopathy (PPCM) and to determine the influence of acute kidney injury (AKI) on the LV function of the patients.

Methods

Sixty patients with PPCM were recruited between January 2007 and June 2018, among which 11 had AKI. The participants were divided into two groups, the recovery group (32 cases) and the nonrecovery group (28 cases), with their clinical features, echocardiography and electrocardiogram findings, laboratory results, and treatments compared between groups. We further determined the risk factors associated with nonrecovery and the influence posed by AKI on the LV function of the patients.

Results

Compared with the patients in the recovery group, those in the nonrecovery group had higher proportions of multiparity [78.6% (22/28) vs. 43.8% (14/32)], function class III– IV heart failure [92.9% (26/28) vs. 71.9% (23/32)], and a higher incidence of AKI [35.7% (10/28) vs. 3.1% (1/32)]. Logistic regression analysis showed that having AKI [odds ratio (OR): 10.556; 95% confidence interval (CI) 1.177–94.654; P = 0.035] and left ventricular ejection fraction (LVEF) < 40% [OR: 4.533; 95% CI 1.118–18.382; P = 0.034] were independently associated with nonrecovery of PPCM.

Conclusions

The prognosis of patients with PPCM and AKI during hospitalization was poor compared to those without AKI; therefore, clinicians should pay more attention to this phenomenon.

Clinical Features and Outcomes of Peripartum Cardiomyopathy in Nigeria

BACKGROUND

Nigeria has the highest incidence of peripartum cardiomyopathy (PPCM) in the world. However, data on PPCM-related outcomes are limited.

OBJECTIVES

The purpose of this study was to examine the clinical profile, myocardial remodeling, and survival of patients with PPCM in Nigeria.

METHODS

This study consecutively recruited 244 PPCM patients (median 7 months postpartum) at 14 sites in Nigeria and applied structured follow-up for a median of 17 months (interquartile range: 14 to 20 months). Left ventricular reverse remodeling (LVRR) was defined as the composite of left ventricular (LV) end-diastolic dimension <33 mm/m² and absolute increase in left ventricular ejection fraction (LVEF) ≥10%. LV full recovery was defined as LVEF ≥55%.

RESULTS

Overall, 45 (18.7%) patients died during follow-up. Maternal age <20 years (hazard ratio [HR]: 2.40; 95% confidence interval (CI): 1.27 to 4.54), hypotension (HR: 1.87; 95% CI: 1.02 to 3.43), tachycardia (HR: 2.38; 95% CI: 1.05 to 5.43), and LVEF <25% at baseline (HR: 2.11; 95% CI: 1.12 to 3.95) independently predicted mortality. Obesity (HR: 0.16; 95% CI: 0.04 to 0.55) and regular use of beta-blockers at 6-month follow-up (HR: 0.20; 95% CI: 0.09 to 0.41) were independently associated with reduced risk for mortality. In total, 48 patients (24.1%) achieved LVRR and 45 (22.6%) achieved LV full recovery. LVEF <25% at baseline (HR: 0.66; 95% CI: 0.47 to 0.92) and regular use of beta-blockers at 6-month follow-up (HR: 1.62; 95% CI: 1.17 to 2.25) independently determined the risk for LV full recovery. Progressive reverse remodeling of all cardiac chambers was observed. In total, 18 patients (7.4%) were hospitalized during the study.

CONCLUSIONS

This is the largest study of PPCM in Africa. Consistent with late presentations, the mortality rate was high, whereas frequencies of LVRR and LV full recovery were low. Several variables predicted poor outcomes, and regular use of beta-blockers correlated with late survival and LV functional recovery.

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.