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Bouabdallaoui N, Mouquet F, Lebreton G, Demondion P, Le Jemtel TH, Ennezat PV. Current knowledge and recent development on management of peripartum cardiomyopathy. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2015; 6:359-366. [PMID: 26474841 DOI: 10.1177/2048872615612465] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Heart failure with left ventricular dysfunction occurring during pregnancy or during the post-partum period in patients without history of cardiovascular disease defines peripartum cardiomyopathy (PPCM). PPCM carries a high morbidity and mortality rate as well as the possibility of recovery ad integrum. Its incidence shows ethnic variations, with a greater prevalence of the disease among women with African descent. Pathogenesis of PPCM remains poorly understood. Both "oxidative stress-prolactin axis" and "anti-angiogenic-signaling excess" hypotheses are currently being investigated. Novel diagnostic strategies and biomarkers are currently being evaluated. Besides conventional treatment of heart failure, targeted therapies such as pharmacological prolactin blockade are under evaluation. The aim of this short review is to highlight current management as targeted therapy has far been disappointing.
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Affiliation(s)
| | | | - Guillaume Lebreton
- 1 Cardio-Thoracic Surgery Department, Pitié-Salpétrière Hospital, France
| | - Pierre Demondion
- 1 Cardio-Thoracic Surgery Department, Pitié-Salpétrière Hospital, France
| | | | - Pierre V Ennezat
- 4 Department of Cardiology, Centre Hospitalier Universitaire de Grenoble, France
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2
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Jaiswal A, Rashid M, Balek M, Park C. Acute myocardial infarction during pregnancy: a clinical checkmate. Indian Heart J 2013; 65:464-8. [PMID: 23993012 DOI: 10.1016/j.ihj.2013.06.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Revised: 03/06/2013] [Accepted: 06/19/2013] [Indexed: 02/01/2023] Open
Abstract
Acute myocardial infarction (AMI) in pregnancy is associated with high morbidity and mortality. Management of these patients can be challenging as little is known about the optimal management strategy. Medications routinely used may have harmful effects on the pregnancy outcome. In addition, AMI could occur in the absence of atherosclerotic disease. We describe optimal management strategy by eliciting the management of a 45-year-old female with ST segment elevation myocardial infarction. We recommend early use of coronary angiography to define the pathology in such cases. Radial artery assess should be preferred. Pregnant patients with AMI due to atherosclerotic disease should be given a 325 mg of aspirin and 600 mg of clopidogrel and either balloon angioplasty or bare metal stent should be used for revascularization. Percutaneous coronary intervention with heparin is preferred over bivalirudin and later should be reserved for patients with severe heparin allergy.
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Affiliation(s)
- Abhishek Jaiswal
- New York Hospital Queens, Weill Medical College of Cornell University, New York 11355, USA.
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Abstract
Peripartum cardiomyopathy (PPCM) is a rare form of unexplained cardiac failure of unknown origin, unique to the pregnant woman with highly variable outcome associated with high morbidity and mortality. PPCM is fraught with controversies in its definition, epidemiology, pathophysiology, diagnosis and management. PPCM is frequently under diagnosed, inadequately treated and without a laid down follow-up regimen, thus, the aim of this review. Publications on PPCM were accessed using Medline, Google scholar and Pubmed databases. Relevant materials on PPCM, selected references from internet services, journals, textbooks, and lecture notes on PPCM were also accessed and critically reviewed. PPCM is multifactorial in origin. It is a diagnosis of exclusion and should be based on classic echocardiographic criteria. The outcome of PPCM is also highly variable with high morbidity and mortality rates. Future pregnancies are not recommended in women with persistent ventricular dysfunction because the heart cannot tolerate increased cardiovascular workload associated with the pregnancy. Although, multiparity is associated with PPCM, there is an increased risk of fetal prematurity and fetal loss. PPCM is a rare form of dilated cardiomyopathy of unknown origin, unique to pregnant women. The pathophysiology is poorly understood. Echocardiography is central to diagnosis of PPCM and effective treatment monitoring in patients of PPCM. The outcome is highly variable and related to reversal of ventricular dysfunction.
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Affiliation(s)
- TC Okeke
- Department of Obstetrics and Gynecology, University of Nigeria Teaching Hospital, Enugu, Nigeria
| | - CCT Ezenyeaku
- Department of Obstetrics and Gynecology, Anambra State University Teaching Hospital, Awka, Nigeria
| | - LC Ikeako
- Department of Obstetrics and Gynecology, Anambra State University Teaching Hospital, Awka, Nigeria
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Abstract
During pregnancy, there are a number of important changes to cardiovascular function which are necessary for progression of a successful pregnancy. Additionally, preexisting cardiovascular conditions can be exacerbated by the adaptations that occur during gestation. These can present serious therapeutic challenges in the management of the cardiology patient during pregnancy. Significantly, the number of pregnant women at risk of cardiovascular complications is on the rise, so identification of risk factors that predict cardiac outcomes is essential to proper screening of the obstetrical patient. In diagnosed preexisting conditions, such as pulmonary hypertension, counseling is important prior to pregnancy. In the case of underlying disorders unmasked by pregnancy, or new-onset complications like preeclampsia, appropriate monitoring and treatment of the cardiovascular complications is warranted. Ultimately, collaborative care by both obstetricians and cardiologists is essential for the successful resolution of cardiovascular dysfunction in the obstetrical patient.
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Abe T, Amano I, Sawa R, Akira S, Nakai A, Takeshita T. Recovery from peripartum cardiomyopathy in a Japanese woman after administration of bromocriptine as a new treatment option. J NIPPON MED SCH 2011; 77:226-30. [PMID: 20818143 DOI: 10.1272/jnms.77.226] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Peripartum cardiomyopathy (PPCM) is a form of heart failure that occurs in women within 1 month before delivery and 5 months after delivery. The outcome of PPCM is variable but improves significantly when appropriate medication is administered in the acute phase; furthermore, the outcome does not worsen even after discontinuation of therapy in the chronic phase. The symptoms and signs of PPCM are similar to those of idiopathic dilated cardiomyopathy. The medical management of patients with PPCM is similar to that for other other forms of heart failure. Recent experimental data implicate a casual role of prolactin in the development of PPCM. Prolactin secretion can be reduced with bromocriptine which had beneficial effects in a small study. We present a Japanese woman with acute PPCM treated with bromocriptine as a therapeutic option. Following treatment, the serum prolactin levels dropped swiftly. Concurrently, LV function improved, and heart failure symptoms decreased, accompanied by a decrease in the BNP level.
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Affiliation(s)
- Takashi Abe
- Division of Reproductive Medicine, Perinatology and Gynecologic Oncology, Graduate School of Medicine, Nippon Medical School, Bunkyo-ku, Tokyo, Japan.
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Nelson M, Moorhead A, Yost D, Whorton A. A 35-Year-Old Pregnant Woman Presenting with Sudden Cardiac Arrest Secondary to Peripartum Cardiomyopathy. PREHOSP EMERG CARE 2011; 16:299-302. [DOI: 10.3109/10903127.2011.615010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Bhakta P, Mishra P, Bakshi A, Langer V. Case report and mini literature review: anesthetic management for severe peripartum cardiomyopathy complicated with preeclampsia using sufetanil in combined spinal epidural anesthesia. Yonsei Med J 2011; 52:1-12. [PMID: 21155028 PMCID: PMC3017683 DOI: 10.3349/ymj.2011.52.1.1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Peripartum cardiomyopathy (PPCM) is a rare entity, and anesthetic management for cesarean section of a patient with this condition can be challenging. We hereby present the anesthetic management of a patient with PPCM complicated with preeclampsia scheduled for cesarean section, along with a mini review of literature. A 24 year-old primigravida with twin gestation was admitted to our hospital with severe PPCM and preeclampsia for peripartum care, which finally required a cesarean section. Preoperative optimization was done according to the goal of managing left ventricular failure. Combined spinal epidural (CSE) anaesthesia with bupivacaine and sufentanil was used for cesarean section under optimal monitoring. The surgery was completed without event or complication. Postoperative pain relief was adequate and patient required only one epidural top up with sufentanil 6 hours after operation. To the best of our knowledge there is no report in literature of the use of sufentanil as a neuraxial opioid in the anesthetic management of cesarean section in a patient with PPCM. CSE with sufentanil may be a safer and more effective alternative in such cases.
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Affiliation(s)
- Pradipta Bhakta
- Department of Anesthesiology, Sultan Quaboos University Hospital, Muscat, Sultanate of Oman
| | - Pragnyadipta Mishra
- Department of Anesthesiology, University of Florida College of Medicine-Jacksonville, Fl, USA
| | - Anamika Bakshi
- Department of Anesthesiology, Moolchand Hospital, New Delhi, India
| | - Vijay Langer
- Department of Anesthesiology, Moolchand Hospital, New Delhi, India
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Abstract
Dilated cardiomyopathy (DC) is a rare but potentially fatal complication of epidermolysis bullosa. No clear cause for it has been identified, but iron overload, low carnitine, low selenium, concomitant viral illness, chronic anemia, and medications have been proposed as possible contributors to the development of DC in reported cases. Early detection allows for medical treatment that delays clinical progression and prolongs survival.
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Recovery and recurrence of left ventricular systolic dysfunction in patients with idiopathic dilated cardiomyopathy. Can J Cardiol 2009; 25:e147-50. [PMID: 19417864 DOI: 10.1016/s0828-282x(09)70497-0] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Some patients with nonischemic left ventricular (LV) systolic failure recover to have normal LV systolic function. However, few studies on the rates of recovery and recurrence have been reported, and no definitive indicators that can predict the recurrence of LV dysfunction in recovered idiopathic dilated cardiomyopathy (IDCMP) patients have been determined. It was hypothesized that patients who recovered from nonischemic LV dysfunction have a substantial risk for recurrent heart failure. METHODS Forty-two patients (32 men) with IDCMP (mean [+/- SD] age 56.9+/-8.7 years) who recovered from systolic heart failure (LV ejection fraction [LVEF] of 26.5+/-6.9% at initial presentation) to a near-normal state (LVEF of 40% or greater, and a 10% increase or greater in absolute value) were monitored for recurrence of LV systolic dysfunction. Patients with significant coronary artery disease were excluded. Patients were monitored for 41.0+/-26.3 months after recovery (LVEF 53.4+/-7.6%) from LV dysfunction. RESULTS LV systolic dysfunction reappeared (LVEF 27.5+/-8.1%) during the follow-up period in eight of 42 patients (19.0%). No significant difference between the groups with or without recurrent heart failure was observed in the baseline clinical and echocardiographic characteristics. However, more patients in the recurred IDCMP group than those in the group that maintained the recovery state had discontinued antiheart failure medication (62.5% versus 5.9%, P<0.05). CONCLUSIONS LV dysfunction recurs in some patients with reversible IDCMP. The recurrence was significantly correlated with the discontinuation of antiheart failure drugs. The results suggest that continuous medical therapy may be mandatory in patients who recover from LV systolic dysfunction.
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Lata I, Gupta R, Sahu S, Singh H. Emergency management of decompensated peripartum cardiomyopathy. J Emerg Trauma Shock 2009; 2:124-8. [PMID: 19561973 PMCID: PMC2700591 DOI: 10.4103/0974-2700.50748] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2008] [Accepted: 11/22/2008] [Indexed: 12/16/2022] Open
Abstract
Peripartum cardiomyopathy (PPCM) is a rare life-threatening cardiomyopathy of unknown cause that occurs in the peripartum period in previously healthy women.[1] the symptomatic patients should receive standard therapy for heart failure, managed by a multidisciplinary team. The diagnosis of PPCM rests on the echocardiographic identification of new left ventricular systolic dysfunction during a limited period surrounding parturition. Diagnostic criteria include an ejection fraction of less than 45%, fractional shortening of less than 30%, or both, and end-diastolic dimension of greater than 2.7 cm/m(2) body surface-area. This entity presents a diagnostic challenge because many women in the last month of a normal pregnancy experience dyspnea, fatigue, and pedal edema, symptoms identical to early congestive heart failure. There are no specific criteria for differentiating subtle symptoms of heart failure from normal late pregnancy. Therefore, it is important that a high index of suspicion be maintained to identify the rare case of PPCM as general examination showing symptoms of heart failure with pulmonary edema. PPCM remains a diagnosis of exclusion. No additional specific criteria have been identified to allow distinction between a peripartum patient with new onset heart failure and left ventricular systolic dysfunction as PPCM and another form of dilated cardiomyopathy. Therefore, all other causes of dilated cardiomyopathy with heart failure must be systematically excluded before accepting the designation of PPCM. Recent observations from Haiti[2] suggest that a latent form of PPCM without clinical symptoms might exist. The investigators identified four clinically normal postpartum women with asymptomatic systolic dysfunction on echocardiography, who subsequently either developed clinically detectable dilated cardiomyopathy or improved and completely recovered heart function.
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Affiliation(s)
- Indu Lata
- Department of Obstetrics and Gynaecology V.M.M.C and Safdarjung Hospital, N. Delhi, India
| | - Renu Gupta
- Department of Obstetrics and Gynaecology, G.S.V.M. Medical College, Kanpur, India
| | - Sandeep Sahu
- Department of Anaesthesiology, G.S.V.M. Medical College, Kanpur, India
| | - Harpreet Singh
- Department of Anaesthesiology, G.S.V.M. Medical College, Kanpur, India
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Bhakta P, Biswas BK, Banerjee B. Peripartum cardiomyopathy: review of the literature. Yonsei Med J 2007; 48:731-47. [PMID: 17963329 PMCID: PMC2628138 DOI: 10.3349/ymj.2007.48.5.731] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2007] [Accepted: 07/31/2007] [Indexed: 12/31/2022] Open
Abstract
Peripartum cardiomyopathy (PPCM) is a rare but serious form of cardiac failure affecting women in the last months of pregnancy or early puerperium. Clinical presentation of PPCM is similar to that of systolic heart failure from any cause, and it can sometimes be complicated by a high incidence of thromboembolism. Prior to the availability of echocardiography, diagnosis was based only on clinical findings. Recently, inclusion of echocardiography has made diagnosis of PPCM easier and more accurate. Its etiopathogenesis is still poorly understood, but recent evidence supports inflammation, viral infection and autoimmunity as the leading causative hypotheses. Prompt recognition with institution of intensive treatment by a multidisciplinary team is a prerequisite for improved outcome. Conventional treatment consists of diuretics, beta blockers, vasodilators, and sometimes digoxin and anticoagulants, usually in combination. In resistant cases, newer therapeutic modalities such as immunomodulation, immunoglobulin and immunosuppression may be considered. Cardiac transplantation may be necessary in patients not responding to conventional and newer therapeutic strategies. The role of the anesthesiologist is important in perioperative and intensive care management. Prognosis is highly related to reversal of ventricular dysfunction. Compared to historically higher mortality rates, recent reports describe better outcome, probably because of advances in medical care. Based on current information, future pregnancy is usually not recommended in patients who fail to recover heart function. This article aims to provide a comprehensive updated review of PPCM covering etiopathogeneses, clinical presentation and diagnosis, as well as pharmacological, perioperative and intensive care management and prognosis, while stressing areas that require further research.
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Affiliation(s)
- Pradipta Bhakta
- Registrar, Department of Anesthesiology, Sultan Quaboos University Hospital, Muscat, Oman
| | - Binay K Biswas
- Teaching Instructor, Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Basudeb Banerjee
- Professor and Head, Department of Gynecology and Obstetrics, B. P. Koirala Institute of Health Sciences, Dharan, Nepal
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Li YB, Hu CL, Zhang JM, Zou YG, Tang YH, Chen JB, Tang QZ, Huang CX. WITHDRAWN: Cardiac Troponin T: An Early Molecule Marker of Normalization of Left Ventricular Ejection Fraction in Patients with Peripartum Cardiomyopathy. Cardiology 2007; 108:345-350. [PMID: 17299263 DOI: 10.1159/000099107] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2006] [Accepted: 10/12/2006] [Indexed: 11/19/2022]
Abstract
The article entitled, "Cardiac Troponin T: An Early Molecule Marker of Normalization of Left Ventricular Ejection Fraction in Patients with Peripartum Cardiomyopathy", by Li et al, which originally was published in this space, has been removed because an article by the same authors and reporting very similar work already has been published in HEART [Published Online First: 25 October 2006], entitled, "Troponin T measurement can predict persistent left ventricular dysfunction in peripartum cardiomyopathy", by Hu et al. The printed version of the article in HEART can be found at Heart 2007;93:488-490.
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Affiliation(s)
- Yan-Bo Li
- Departments of Obstetrics and Gynecology, Renmin Hospital of Wuhan University, Wuhan, PR China
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Abstract
Peripartum cardiomyopathy is a rare and under recognized form of dilated cardiomyopathy, defined as a heart failure in the last month of pregnancy or in the first five months post-partum with absence of determinable cause for cardiac failure and absence of demonstrable heart disease. The incidence of peripartum cardiomyopathy ranges from 1 in 1300 to 1 in 15,000 pregnancy. Advanced maternal age, multiparity, twin births, preeclampsia and black race are known risk factors. The etiology of peripartum cardiomyopathy remains unknown but viral, autoimmune or idiopathic myocarditis are highly suggested. The clinical presentation on patients with peripartum cardiomyopathy is similar to that of patients with systolic heart failure. The treatment is based on drugs for sympyomatic control. Studies in graeter populations are need to determine the role of immunosupressive treatment. About half patients of peripartum cardiomyopathy recover. The left ventricular ejection fraction and the left ventricular end-diastolic diameter are statistically significant prognostic factors. The risk of developing peripartum cardiomyopathy in subsequent pregnancies remains high. The place of dobutamine stress test in counseling the patients who desire pregnancy must be more studied.
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Affiliation(s)
- S Fennira
- Service de Cardiologie et Angiologie, CHU Mongi-Slim, Tunisie.
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Abstract
Peripartum cardiomyopathy (PPCM) is a disorder in which initial left ventricular systolic dysfunction and symptoms of heart failure occur between the late stages of pregnancy and the early postpartum period. It is common in some countries and rare in others. The causes and pathogenesis are poorly understood. Molecular markers of an inflammatory process are found in most patients. Clinical presentation includes usual signs and symptoms of heart failure, and unusual presentations relating to thromboembolism. Clinicians should consider PPCM in any peripartum patient with unexplained disease. Conventional heart failure treatment includes use of diuretics, beta blockers, and angiotensin-converting enzyme inhibitors. Effective treatment reduces mortality rates and increases the number of women who fully recover left ventricular systolic function. Outcomes for subsequent pregnancy after PPCM are better in women who have first fully recovered heart function. Areas for future research include immune system dysfunction, the role of viruses, non-conventional treatments such as immunosuppression, immunoadsorption, apheresis, antiviral treatment, suppression of proinflammatory cytokines, and strategies for control and prevention.
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Affiliation(s)
- Karen Sliwa
- Soweto Cardiovascular Research Unit, Department of Cardiology, Chris-Hani-Baragwanath Hospital, University of the Witwatersrand, P O Bertsham 2013, Johannesburg, South Africa.
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de Beer T. Peripartum Cardiomyopathy in a DGH Setting — Case Report and Literature Review. J Intensive Care Soc 2005. [DOI: 10.1177/175114370500600313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Thearina de Beer
- SpR Anaesthetics and ICM Oxford Rotation Milton Keynes General Hospital
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Abstract
OBJECTIVE To provide a review of the cardiac and obstetrical literature regarding the development of peripartum cardiomyopathy and, in particular, to examine risk factors, incidence, diagnosis, prognosis, and evidence-based treatment modalities. DESIGN An extensive review of the current literature. RESULTS Peripartum cardiomyopathy is a cardiomyopathy of unknown cause that occurs in pregnant females, most commonly in the early postpartum period. It shares many clinical characteristics with idiopathic dilated cardiomyopathy but occurs at a younger age and is associated with a better prognosis. Diagnosis is based upon the clinical presentation of congestive heart failure and objective evidence of left ventricular systolic dysfunction. Conventional pharmacologic therapy for congestive heart failure, such as diuretics, digoxin, angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, and beta-adrenergic blockers, are routinely used and are quite effective. For those patients who remain refractory to conventional pharmacologic therapy, cardiac transplantation and mechanical circulatory support are viable options. CONCLUSION Mortality rates in peripartum cardiomyopathy have decreased, and this is most likely related to advances over the past 5 yrs in medical therapy for heart failure. Aggressive use of implantable defibrillators has significantly reduced the risk of sudden death in these patients. For >50% of peripartum cardiomyopathy patients, left ventricular function normalizes with pharmacologic therapy. However, subsequent pregnancies almost always are associated with recurrence of left ventricular systolic dysfunction.
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Affiliation(s)
- Srinivas Murali
- University of Pittsburgh School of Medicine, Clinical Services of the Heart Failure Network, and Pulmonary Hypertension Program, Pittsburgh, PA, USA
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