Overdiagnosis of peripartum cardiomyopathy in pregnancy: A prospective echocardiographic cohort study

Peripartum cardiomyopathy (PPCM) can lead to long-term systolic dysfunction, especially among black women. Hypertensive disorders of pregnancy (HDP) are the strongest risk factor for PPCM, but controversy remains on whether HDP predict a favorable outcome. Women with HDP are also often diagnosed with PPCM earlier than those without HDP. Our objective is to determine recovery of systolic function in patients with PPCM stratified by HDP, timing of diagnosis, and race. We conducted a retrospective cohort study of 220 patients (55% black) diagnosed with PPCM. Patients with PPCM and HDP were diagnosed earlier postpartum than patients without HDP (P=0.013), an effect that was most pronounced in nonblack patients. Rates of left ventricular ejection fraction (LVEF) recovery were similar among PPCM patients with and without HDP (68.4% versus 62.6%, P=0.425). In contrast, patients with PPCM diagnosed after 1-month postpartum had lower rates of LVEF recovery than patients diagnosed <1-month postpartum (53.7% versus 69.9%, P=0.035). LVEF at time of diagnosis is a strong predictor of LVEF recovery, and patients with PPCM diagnosed after 1-month postpartum had lower baseline LVEF compared to patients presenting earlier (P=0.041). The presence of HDP does not correlate with LVEF recovery in our racially diverse PPCM cohort. In contrast, early diagnosis portends a favorable outcome. Early diagnosis is associated with higher LVEF at presentation, likely explaining the improved outcomes in these women. These findings underscore the need for early monitoring and diagnosis, especially in at-risk and underserved populations.

33-Year-Old Woman With Postpartum Acute Shortness of Breath

Race, hypertensive disorders of pregnancy and outcomes in peripartum cardiomyopathy

Peripartum cardiomyopathy and pre-eclampsia: two tips of the same iceberg.

Cardiac structure and function are affected both by acromegaly and hyperthyroidism. Whereas the former is mainly characterized by ventricular hypertrophy as well as diastolic and systolic impairment, the latter frequently leads to increased heart rate and enhancement of contractility and cardiac output. To further investigate this issue, we designed this two-arm study. In the first cross-sectional study, we compared echocardiography and radionuclide angiography results obtained in eight hyperthyroid acromegalic patients, eight hyperthyroid nonacromegalic patients, and eight healthy subjects. All acromegalic patients were receiving treatment for acromegaly at the onset of hyperthyroidism. In the second longitudinal study, performed in the group of acromegalic patients, we compared the cardiovascular results obtained during hyperthyroidism with the retrospective data obtained at the initial diagnosis of acromegaly and after 1-yr treatment for this disease and those prospective data obtained during the remission of hyperthyroidism. In the cross-sectional study, hyperthyroid acromegalic patients showed an increase in the left ventricular (LV) mass index (LVMi) compared to healthy and hyperthyroid controls (P < 0.05), with evidence of LVMi hypertrophy in five of them (62.5%). A significant correlation was found between LVMi and GH levels (r = 0.785; P < 0.05). The LV ejection fraction (LVEF) at rest was higher in the control hyperthyroid population than in healthy controls (P < 0.05), whereas the LVEF response to exercise was reduced in acromegalic patients (P < 0.05 vs. healthy controls). In acromegalics, the exercise-induced change in LVEF was significantly reduced compared to that in healthy controls (P < 0.001), but not to that in hyperthyroid controls (P < 0.07), being abnormal (<5% increase vs. baseline values) in six patients. Four of these six patients (66%) had elevated GH and insulin-like growth factor I levels during the treatment of acromegaly. An inverse correlation between GH and LVEF at rest (r = -0.896;P < 0.05) and at peak exercise (r = -0.950; P < 0.001) was recorded. The peak filling rate was reduced in hyperthyroid acromegalic patients compared to those in both control populations (P < 0.05). In the longitudinal study, acromegalic patients showed an increased LVMi during hyperthyroidism compared to that observed after successful treatment of acromegaly (P < 0.05); resting LVEF was increased compared to both basal (P < 0.001) and posttreatment values (P < 0.05). However, the exercise-induced change in LVEF was reduced (P < 0.05 vs. previous follow-up values). Remission of hyperthyroidism led to significant reduction of LVMi (P < 0.05) and resting LVEF (P < 0.05) and an increase in exercise-induced LVEF (P < 0.05). In light of these findings, hyperthyroidism produces a detrimental effect on the cardiovascular system of acromegalic patients, particularly in those with uncontrolled disease. Thus, control of GH and insulin-like growth factor I should be a major objective, as cardiovascular risk persists in patients with ineffective hormonal suppression, and constant endocrine and cardiovascular surveillance remain crucial steps in patient follow-up.

Peripartum Cardiomyopathy

Effects of Bromocriptine in Peripartum Cardiomyopathy: A Systematic Review and Meta-analysis

Recent studies suggest that angiogenic imbalance during pregnancy may lead to acute peripartum cardiomyopathy (PPCM). We propose that angiogenic imbalance and residual cardiac dysfunction may exist even after recovery from PPCM. Twenty-nine women at least 12 months after presentation with PPCM, who exhibited recovery of left ventricular (LV) ejection fraction (≥50%), were included in the study (mean age 35±6 years, LV ejection fraction 61.0±3.9%). The number of circulating endothelial progenitor cells (EPCs) and plasma levels of proangiogenic vascular endothelial growth factor and of soluble vascular endothelial growth factor receptor Flt1 (sFlt1) were measured. All patients underwent comprehensive cardiac function assessment, including tissue Doppler imaging and 2-dimensional (2D) strain echocardiography. All measurements were compared with healthy controls. Patients with a history of PPCM have significantly higher sFlt1 concentrations (median [25th-75th percentile]; 149.57, [63.14-177.89] versus 20.29, [15.00-53.89] pg/mL, P<0.001) and significantly decreased vascular endothelial growth factor/sFlt1 ratio (P=0.012) compared with controls, with a trend toward lower concentration of circulating CD34+/KDR+ levels. In addition, patients with PPCM had lower early velocities E' septal (9.9±2.1 versus 11.0±1.5 cm/s, P=0.02), with a significantly lower systolic velocity S' septal (7.6±1.2 versus 8.5±1.2 cm/s, P=0.003) by tissue Doppler imaging. Significantly lower LV global longitudinal (-19.1±3.3 versus -22.7±2.2%, P<0.001) and apical circumferential 2D strain (-16.6±4.9 versus -21.2±7.9, P=0.02) were present in patients with PPCM compared with controls. Higher concentration of sFlt1 with concomitant decreased circulating endothelial progenitor cell levels along with inappropriate attenuated vascular endothelial growth factor levels may imply an angiogenic imbalance that exists even after recovery and may thus predispose to PPCM. In addition, tissue Doppler imaging and 2D strain were able to identify residual myocardial injury in post-PPCM women with apparent recovery of LV systolic function. Both angiogenic imbalance and residual myocardial injury may play an important role in the recurrence of LV dysfunction during subsequent pregnancies.

Background Peripartum Cardiomyopathy (PPCM) frequently affects women of African descent. There is scarcity of data pertaining to the clinical presentation and outcomes of PPCM patients in Uganda, particularly when employing modern diagnostic tools and adhering to guideline-directed medical therapy (GDMT). Purpose We aimed to delineate the clinical characteristics, echocardiographic findings, and 6-month outcomes among women in Uganda diagnosed with PPCM. Methods Prospective case-control design conducted from June 2022 to August 2023. We enrolled 80 PPCM cases and 80 matched controls. Inclusion criteria comprised: (i) peripartum state, (ii) signs and symptoms of HF, (iii) left ventricular (LV) ejection fraction ≤ 45%, and (iv) exclusion of alternative causes of HF. Controls were healthy women matched for age and parity. Over a 6-month period, enrolled PPCM cases were diligently monitored while on GDMT. All participants underwent a physical examination, 12-lead electrocardiography, and a detailed echocardiography incorporating global longitudinal strain measurements at both baseline and the 6-month follow-up. Results At baseline, amongst the cases, the mean age was 33.6 ± 6.6 years, mean parity was 3±2.1 pregnancies. HF onset occurred within 9.5±6.5 weeks post-delivery. A total of 20 (25.0%) cases presented in NYHA Class 4 with dyspnea as the predominant symptom in 79.95% of cases. Atrial fibrillation (AF) was observed in 2(2.5%) patients. In comparison with healthy controls, high gravidity (0.2±1.0; p&amp;lt;0.001) was identified as the only predictor of PPCM in this study. (Table 1) At 6-months follow up, the mean LV ejection fraction (LVEF) showed improvement from 35.7±-11.0% to 45.9 ± 15.7% (p&amp;lt;0.001) accompanied by a reduction in left ventricular diameter (LVD) from 6.1±0.7 cm to 5.5±1cm(p&amp;lt;0.001). At the 6-month follow-up, recovery (LVEF ≥ 50%) occurred in 37 cases (55%), and 52 (65%)patients were asymptomatic (NYHA Class 1) at the 6-month follow-up. Six-month mortality data were available for 5(6.3%) women, and one patient successfully underwent the insertion of an Implantable Cardioverter-defibrillator for recurrent Ventricular Tachycardia. Regarding GDMT, 55 participants received Bromocriptine as part of their medication. Twenty(25%) patients received anticoagulation for AF(n=2) or intracardiac thrombus (n=6, 1.67%) (Figure 1) resulting in 2(2.5%) strokes within the 6-month follow-up. Conclusion The current study demonstrated a comparable mortality rate on GDMT, aligning with contemporary global studies at 7.5%. The observed high thrombus burden in patients may indicate suboptimal adherence to anticoagulation therapy. While the incidence of PPCM remains undefined in Uganda, the primary predisposing factor identified was high gravidity. A noteworthy proportion of patients exhibited incomplete LV recovery, suggesting the need for larger studies to comprehensively define the maternal and fetal outcomes in Uganda.Figure 1Table 1

No Acute Changes in LVEF Observed With Concurrent Trastuzumab and Breast Radiation With Low Heart Doses

Background: We report a case of Peri-Partum Cardiomyopathy in a 28-year-old Primigravida, who came in labor and underwent a Caesarean Section in view of meconium-stained liquor, fetal distress. On day 4 post-partum, she complained of a sudden onset of shortness of breath, cough, and restlessness in the morning. The patient had no prior history of heart disease or respiratory disease. Patient developed sudden onset tachypnoea and tachycardia with bilateral crepitus. On further evaluation, she was diagnosed with Peripartum Cardiomyopathy. Results: The case was successfully managed by a multi-disciplinary team using dobutamine, diuretics, and Angiotensin receptor blockers. Conclusion: The case report aims to present a case of Peripartum cardiomyopathy with early diagnosis and successful management in a secondary care level hospital. Peripartum (postpartum) cardiomyopathy is the most common cardiomyopathy in pregnancy, defined as an idiopathic cardiomyopathy that presents with heart failure secondary to left ventricular systolic dysfunction toward the end of pregnancy or after delivery, in the absence of any other cause of heart failure. It is a diagnosis of exclusion, and the majority are diagnosed postpartum. Although the LV may not be dilated, the ejection fraction is nearly always reduced below 45%. Incidence of PPCM is 1:3000 to 1:15000 pregnancies. It is a major cause of morbidity and mortality if diagnosis gets delayed; therefore, early diagnosis and timely management can affect patients’ long-term prognosis. This case report aims to raise awareness in health professionals about the possibilities of PPCM and its symptoms, as in our case.

Peripartum cardiomyopathy (PPCM) is a disorder of pregnant women that most often asserts itself in the early postpartum period, and whose cause is unknown. With appropriate treatment, some patients recover fully within 6 months, but those who continue to have ventricular dysfunction have a very poor outlook. Prompt recognition of PCM is necessary for appropriate medical management and for counseling about future pregnancies. This prospective multicenter trial examined the prognostic value of serum cardiac troponin (cTnT), which is a specific and very sensitive marker of myocardial injury. Participating were 106 patients with newly diagnosed PPCM who presented to one of 3 teaching hospitals in central China. The criteria for diagnosis of PPCM were congestive heart failure starting in the last month of pregnancy or up to 5 months after delivery, a left ventricular ejection fraction (LVEF) <40%, and no other identifiable cause of cardiac dysfunction. Levels of cTnT were measured and the LVEF was determined by echocardiography within 2 weeks of the onset of cardiomyopathy, and the echocardiogram was repeated 6 months later. The criterion for depressed function was a LVEF <40%. At the time of diagnosis, all the study patients had pulmonary edema and 86% had elevated serum levels of cTnT (0.01 ng/mL or higher). LVEF averaged 27% and improved to an average of 45% by the 6-month follow-up. LVEF returned to normal in 52% of patients, but 48% continued to have left ventricular dysfunction. Initial estimates of cTnT correlated negatively with LVEF at follow-up. The investigators used a cTnT concentration of 0.04 ng/mL as a cutoff value based on published information about the assay used. There were 33 patients whose initial cTnT level exceeded 0.04 ng/mL. After 6 months, these patients had a significantly smaller mean LVEF (35.42%; 95% CI, 13.04%–50.16%) and more persistent left ventricular dysfunction. An elevated cTnT concentration predicted persistent left ventricular dysfunction with a sensitivity of 55% and a specificity of 91%. In this study, the serum cTnT level measured within 2 weeks after the onset of PPCM correlated negatively with the LVEF measured 6 months later. This is a simple, comparatively inexpensive, rapid, and noninvasive means of predicting persistent left ventricular dysfunction in women with PPCM.

Peripartum cardiomyopathy (PPCM) is an idiopathic myocardial insufficiency that occurs in the absence of any diagnosed heart disease during the last month of pregnancy or during the first 5 months after delivery. The aim. To improve immediate and long-term maternal outcomes in patients with PPCM by establishing an optimal strategy for its diagnosis, treatment, delivery and medical support during the postpartum period. Materials and methods. The article presents the experience of multidisciplinary medical care for 11 pregnant wo-men and postpartum women with dilated cardiomyopathy (DCM) on the basis of the National Amosov Institute of Cardio-vascular Surgery and the Institute of Pediatrics, Obstetrics and Gynecology named after acad. O. M. Lukianova of NAMS of Ukraine. After the differential diagnosis, 8 women were defined as patients with PPCM, and 3 women had family history of the disease (DCM in relatives). All the patients were examined according to the protocol using the history, examination, and instrumental and laboratory findings. Results. After in-hospital treatment there was an increase in the left ventricular ejection fraction (LVEF) in the group of patients with PPCM from 28.3 ± 9.3% to 37.6 ± 7.6% and a decrease in end-diastolic volume (EDV) from 196.7 ± 47.7 ml to 181.3 ± 59.7 ml, end-systolic volume (ESV) from 104.25 ± 33.3 ml to 94.2 ± 35.1 ml. In four cases, patients with severe left ventricular (LV) dysfunction underwent urgent preterm Cesarean section in the second trimester of pregnancy. There were no early maternal losses, there were two perinatal losses of extremely premature infants (16 and 27 weeks of gesta-tion). In the follow-up period (23.5 ± 11.6 months), LVEF further increased up to 42.9 ± 8.4% and EDV and ESV decreased up to 170.1 ± 49.5 and 82.7 ± 40.6 ml, respectively. In 7 (87.5%) patients with PPCM, a significant improvement in clini-cal condition and pumping function of the heart was registered at the time of discharge from the hospital, and there was further improvement in the indicators for another 12 months, but complete recovery of cardiac function was achieved only in 3 (37.5%) patients. In patients from the group of family type DCM, complete recovery of LV myocardial function was not observed in any of the 3 studied cases. The article discusses the timing of the occurrence and diagnosis of PPCM, the main clinical, instrumental and labora-tory signs of the pathology, methods of cardiological, cardiosurgical and obstetric support of such pregnant women. Conclusions. The terms of the onset of PPCM manifestations may be wider (earlier) according to our observations and should be the subject of further research. The strategy of medical care for pregnant women doesn’t particularly depend on the type of DCM. However, obstetric tactics aimed at early delivery of a patient with PPCM with severe myocardial insufficiency are feasible in combination with interruption of lactation and in most cases allow to achieve compensation of circulation and partial recovery of LV function. Prescription of bromocriptine for this purpose seems appropriate. The use of repeated courses of levosimendan in patients with PPCM is feasible and helps to improve the LV function in the early postpartum period.

30 Maternal cardiac function in twin pregnancy and reeclampsia: A ongitudinal study

Background Peripartum cardiomyopathy (PPCM) is a life-threatening condition with a global incidence of 1 in 2000 births. PPCM has a higher morbidity and mortality in African American (AA) populations, and a worse prognosis associated with delayed presentation. Previous studies suggest that various obstetric complications are associated with an increased risk for developing PPCM. Recently, we identified additional obstetric complications including blood transfusion and premature labor were associated with an increased risk of developing PPCM. However, the relationship between these presentations in respect to race and time to presentation is not well understood. Purpose This study aims to use large cohort study data to characterize racial differences in obstetric complications and their association with time to presentation of PPCM. Methods Public discharge data which included hospital readmission data were obtained from the Agency of Healthcare Research and Quality for the states of Arizona (2003-2007), Florida (2004-2013), and Washington (2003-2012). Hospitalizations reporting a delivery were identified using ICD-9 CM codes (V27.xx). Patient, pregnancy, and obstetric characteristics were determined using ICD-9 CM codes. The primary outcome was a diagnosis of PPCM defined as PPCM coded at any time in the peripartum period within 150 days postpartum, post-delivery presentation was defined as PPCM coded after discharge within this same peripartum period. Patient characteristics were stratified by white, AA, Hispanic. Chi-square test was used for categorical variables and Student’s t-test for continuous variables. Associations were determined using logistic regression. Results In total 3,365,946 delivering mothers were identified. 928 mothers were diagnosed with PPCM, 253 of which were rehospitalized after discharge for PPCM (27.2%). AA race had an increased risk of presenting with PPCM postpartum (95% CI 2.66-3.41, p &amp;lt; 0.001). Previously identified risk factors for PPCM such as AA race, gestational diabetes mellitus (GDM), anemia, hypertensive disorders of pregnancy, and advanced maternal age (AMA), were significantly increased in our PPCM cohort (p&amp;lt;0.001 for all). Notably, post-delivery PPCM hospitalization had higher rates of AMA, GDM, hypertensive disorders of pregnancy, and RBC transfusion (p &amp;lt; 0.001 for all). When further stratifying for race, white and AA patients had a significantly higher risk of post-partum hospitalization for PPCM after transfusion in comparison to Hispanic patients. AA patients were less likely to present with PPCM postpartum following premature labor and C-section, although more likely to present with PPCM postpartum with hypertensive disorders of pregnancy in comparison to their white counterparts. Conclusion The risk profile of obstetric complications in PPCM varies by race and may differentially influence time to presentation.Overall post-delivery PPCM Forest Plot Black post-delivery PPCM Forest Plot