Peripartum Heart Failure With Preserved Ejection Fraction: A Distinct But Under-Recognized Clinical Syndrome

Abstract

Introduction Peripartum cardiomyopathy is a well-described diagnosis characterized by systolic dysfunction. Increasingly recognized is that peripartum women may also develop clinical heart failure with preserved ejection fraction (HFpEF); however, little is known about risk factors, diagnostic criteria, and recurrence. Hypothesis We propose that peripartum HFpEF is an under-recognized entity distinct from peripartum cardiomyopathy and preeclampsia. Peripartum HFpEF may be associated with comorbidities prevalent among other patients with HFpEF and may recur during subsequent pregnancies. Methods We identified pregnant and postpartum patients between 8 weeks antepartum and 7 months postpartum (mean 21 ± 53 days), with symptomatic heart failure and normal ejection fraction (EF) (≥55%) on echocardiogram. Demographics, comorbidities, labs, imaging, treatment, and clinical outcomes were assessed. Outcomes of interest were the association of clinical heart failure with BNP, preeclampsia, and other comorbidities, and long-term outcomes of final EF and subsequent pregnancies. Results Among 44 patients with clinical concern for heart failure, 22 (50%) met clinical diagnostic criteria based on Framingham criteria. Only 2 women (9%) were given a clear diagnosis of HFpEF by providers during their initial presentation. Among patients with HFpEF, 8 (36%) had concomitant preeclampsia. Mean BNP was 208±184 pg/mL, and 4 patients (18%) had BNP below 35 pg/mL. Pulmonary edema was documented in 15 patients (68%). Average non-pregnant BMI was 36.1±7.9 kg/m². Compared with the US adult female population, our cohort had higher prevalence of hypertension (41% vs. 28%), diabetes (36% vs. 12%), and sleep apnea (27% vs. 17%). After 4.7±4.2 years of follow-up, no patients developed systolic dysfunction, 5/22 (23%) women carried an additional term pregnancy, and 1 of those 5 (20%) had recurrent HFpEF during the subsequent pregnancy. Conclusions Peripartum HFpEF is a distinct and under-recognized diagnosis that should be considered in peripartum women with clinical heart failure. Despite clinical symptoms, several women had normal BNP or absent pulmonary edema by chest x-ray, suggesting additional diagnostic criteria may be needed. While preeclampsia is associated with transient cardiac dysfunction, many women with peripartum HFpEF did not have preeclampsia, but did have comorbidities in common with HFpEF. More research is needed to determine longer-term outcomes and risk of recurrence during subsequent pregnancies.