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Falconi S, Okimi A, Wesley S, Sethi P, Datta P, Krutsch K. The concentration of maternal sacubitril/valsartan transferred into human milk is negligible. Front Public Health 2024; 12:1389513. [PMID: 38841677 PMCID: PMC11150817 DOI: 10.3389/fpubh.2024.1389513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 04/22/2024] [Indexed: 06/07/2024] Open
Abstract
Background Peripartum cardiomyopathy (PPCM) is a common cause of heart failure (HF) in the peripartum. Some medications are considered safe while breastfeeding. However, sacubitril/valsartan (Entresto), while efficacious, is not recommended in breastfeeding women due to concerns about adverse infant development, and no published data suggest otherwise. Objectives This study aimed to assess the transfer of sacubitril/valsartan into human milk and evaluate the infant's risk of drug exposure. Methods The InfantRisk Human Milk Biorepository released samples and corresponding health information from five breastfeeding maternal-infant dyads exposed to sacubitril/valsartan. Sacubitril, valsartan, and LBQ657 (sacubitril active metabolite) concentrations were determined using liquid chromatography-mass spectrometry (LC/MS/MS) from timed samples 0, 1, 2, 4, 6, 8, 10, and 12 h following medication administration at steady state conditions. Results Valsartan levels were below the detection limit of 0.19 ng/mL in all milk samples. Sacubitril was measurable in all milk samples of the five participants, peaking 1 h after drug administration at a mean concentration of 1.52 ng/mL for a total infant dose of 0.00049 mg/kg/12 h and a relative infant dose (RID) calculated at 0.01%. The maximum concentration of its active metabolite LBQ657 in the milk samples was observed 4 h after medication administration and declined over the remaining 12-h dosing interval, for an average concentration of 9.5 ng/mL. The total infant dose was 0.00071 mg/kg/12 h, and the RID was 0.22%. Two mothers reported continuing to breastfeed while taking sacubitril/valsartan; both mothers stated observing no negative effects in their breastfed infants. Conclusion The transfer of sacubitril/valsartan into human milk is minimal. These concentrations are unlikely to pose a significant risk to breastfeeding infants, with a combined calculated RID of <0.25%, which is far lower than the industry safety standards (RID <10%).
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Affiliation(s)
- Sirin Falconi
- School of Medicine, Texas Tech University Health Sciences Center, Amarillo, TX, United States
| | - Abiodun Okimi
- School of Medicine, Texas Tech University Health Sciences Center, Amarillo, TX, United States
| | - Shaun Wesley
- Department of Obstetrics and Gynecology, School of Medicine and Dentistry, University of Rochester Medical Center, Rochester, NY, United States
| | - Pooja Sethi
- Department of Cardiology, School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, United States
| | - Palika Datta
- Department of Obstetrics and Gynecology, School of Medicine, Texas Tech University Health Sciences Center, Amarillo, TX, United States
| | - Kaytlin Krutsch
- Department of Obstetrics and Gynecology, School of Medicine, Texas Tech University Health Sciences Center, Amarillo, TX, United States
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2
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El Marraki Z, Mounaouir K, Fellat N, Fellat R. Postpartum dilated cardiomyopathy and antiphospholipid syndrome: A rare association revealed by a pulmonary embolism (case report). Radiol Case Rep 2024; 19:1298-1303. [PMID: 38292781 PMCID: PMC10825536 DOI: 10.1016/j.radcr.2023.11.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 11/15/2023] [Accepted: 11/22/2023] [Indexed: 02/01/2024] Open
Abstract
Antiphospholipid syndrome is a rare entity that must be systematically evoked in front of recurrent miscarriages associated with venous or arterial thrombosis, its diagnosis is based on a set of clinico-biological arguments. In rare cases, it can be associated with postpartum cardiomyopathy, which is defined by a dysfunction of the left ventricle with an LVEF<45%, which may or may not be associated with a dilation of the left ventricle. This association is rare and poorly described in the literature, which makes management difficult and uncodified. In this context we report the case of a 33-year-old patient with cardiovascular risk factors such as arterial hypertension 2 previous miscarriages and repeated phlebitis, she was admitted to the emergency room for the management of acute dyspnea related to a proximal right pulmonary embolism and in whom the transthoracic echocardiography had objectivated a dilated left ventricle and an alteration of the ejection fraction of the left ventricle, the coronary angiography came back without particularity as part of the etiological work-up, a biological work-up was carried out, which came back in favor of an antiphospholipid syndrome. This case shows diagnostic difficulties and management of this disease.
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Affiliation(s)
- Zakaria El Marraki
- Department of Cardiac Intensive Care, Cardiology Intensive Care Unit, Ibn Sina University Hospital, Rabat, Morocco
| | - Karim Mounaouir
- Department of Cardiac Intensive Care, Faculty of Medicine and Pharmacy, Casablanca, Morocco
| | - Nadia Fellat
- Department of Cardiac Intensive Care, Cardiology Intensive Care Unit, Ibn Sina University Hospital, Rabat, Morocco
| | - Rokaya Fellat
- Department of Clinical Cardiology, Faculty of Medicine and Pharmacy, Rabat, Morocco
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3
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Karabayir I, Wilkie G, Celik T, Butler L, Chinthala L, Ivanov A, Moore Simas TA, Davis RL, Akbilgic O. Development and validation of an electrocardiographic artificial intelligence model for detection of peripartum cardiomyopathy. Am J Obstet Gynecol MFM 2024; 6:101337. [PMID: 38447673 DOI: 10.1016/j.ajogmf.2024.101337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Revised: 02/17/2024] [Accepted: 02/27/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND This study used electrocardiogram data in conjunction with artificial intelligence methods as a noninvasive tool for detecting peripartum cardiomyopathy. OBJECTIVE This study aimed to assess the efficacy of an artificial intelligence-based heart failure detection model for peripartum cardiomyopathy detection. STUDY DESIGN We first built a deep-learning model for heart failure detection using retrospective data at the University of Tennessee Health Science Center. Cases were adult and nonpregnant female patients with a heart failure diagnosis; controls were adult nonpregnant female patients without heart failure. The model was then tested on an independent cohort of pregnant women at the University of Tennessee Health Science Center with or without peripartum cardiomyopathy. We also tested the model in an external cohort of pregnant women at Atrium Health Wake Forest Baptist. Key outcomes were assessed using the area under the receiver operating characteristic curve. We also repeated our analysis using only lead I electrocardiogram as an input to assess the feasibility of remote monitoring via wearables that can capture single-lead electrocardiogram data. RESULTS The University of Tennessee Health Science Center heart failure cohort comprised 346,339 electrocardiograms from 142,601 patients. In this cohort, 60% of participants were Black and 37% were White, with an average age (standard deviation) of 53 (19) years. The heart failure detection model achieved an area under the curve of 0.92 on the holdout set. We then tested the ability of the heart failure model to detect peripartum cardiomyopathy in an independent University of Tennessee Health Science Center cohort of pregnant women and an external Atrium Health Wake Forest Baptist cohort of pregnant women. The independent University of Tennessee Health Science Center cohort included 158 electrocardiograms from 115 patients; our deep-learning model achieved an area under the curve of 0.83 (0.77-0.89) for this data set. The external Atrium Health Wake Forest Baptist cohort involved 80 electrocardiograms from 43 patients; our deep-learning model achieved an area under the curve of 0.94 (0.91-0.98) for this data set. For identifying peripartum cardiomyopathy diagnosed ≥10 days after delivery, the model achieved an area under the curve of 0.88 (0.81-0.94) for the University of Tennessee Health Science Center cohort and of 0.96 (0.93-0.99) for the Atrium Health Wake Forest Baptist cohort. When we repeated our analysis by building a heart failure detection model using only lead-I electrocardiograms, we obtained similarly high detection accuracies, with areas under the curve of 0.73 and 0.93 for the University of Tennessee Health Science Center and Atrium Health Wake Forest Baptist cohorts, respectively. CONCLUSION Artificial intelligence can accurately detect peripartum cardiomyopathy from electrocardiograms alone. A simple electrocardiographic artificial intelligence-based peripartum screening could result in a timelier diagnosis. Given that results with 1-lead electrocardiogram data were similar to those obtained using all 12 leads, future studies will focus on remote screening for peripartum cardiomyopathy using smartwatches that can capture single-lead electrocardiogram data.
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Affiliation(s)
- Ibrahim Karabayir
- Section of Cardiovascular Medicine, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC (Drs Karabayir, Celik, Butler, Ivanov, and Akbilgic)
| | - Gianna Wilkie
- Department of Obstetrics & Gynecology, UMass Chan Medical School, Worcester, MA (Drs Wilkie and Simas)
| | - Turgay Celik
- Section of Cardiovascular Medicine, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC (Drs Karabayir, Celik, Butler, Ivanov, and Akbilgic)
| | - Liam Butler
- Section of Cardiovascular Medicine, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC (Drs Karabayir, Celik, Butler, Ivanov, and Akbilgic)
| | - Lokesh Chinthala
- Center for Biomedical Informatics, University of Tennessee Health Science Center, Memphis, TN (Mr Chinthala and Dr Davis)
| | - Alexander Ivanov
- Section of Cardiovascular Medicine, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC (Drs Karabayir, Celik, Butler, Ivanov, and Akbilgic)
| | - Tiffany A Moore Simas
- Department of Obstetrics & Gynecology, UMass Chan Medical School, Worcester, MA (Drs Wilkie and Simas)
| | - Robert L Davis
- Center for Biomedical Informatics, University of Tennessee Health Science Center, Memphis, TN (Mr Chinthala and Dr Davis)
| | - Oguz Akbilgic
- Section of Cardiovascular Medicine, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC (Drs Karabayir, Celik, Butler, Ivanov, and Akbilgic).
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4
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Ejim EC, Karaye KM, Antia S, Isiguzo GC, Njoku PO. Peripartum cardiomyopathy in low- and middle-income countries. Best Pract Res Clin Obstet Gynaecol 2024; 93:102476. [PMID: 38395024 DOI: 10.1016/j.bpobgyn.2024.102476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 12/15/2023] [Accepted: 02/05/2024] [Indexed: 02/25/2024]
Abstract
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.
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Affiliation(s)
- Emmanuel C Ejim
- Department of Medicine, University of Nigeria Ituku-Ozalla Campus, Enugu, Nigeria.
| | - Kamilu M Karaye
- Bayero University & Aminu Kano Teaching Hospital Kano, Nigeria.
| | - Samuel Antia
- Department of Medicine, Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Nigeria.
| | - Godsent C Isiguzo
- Department of Medicine, Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Nigeria.
| | - Paschal O Njoku
- Department of Medicine, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu, Nigeria.
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Warner ED, Farhan S, Bierowski M, Sahawneh F, Oliveros E, Pirlamarla P, Marek-Iannucci S, Ramu B, Ullah W, Brailovsky Y, Rajapreyar IN. Trends in cardiovascular complications of pregnancy: A nationwide inpatient sample analysis. Am J Med Sci 2023; 366:337-346. [PMID: 37678669 DOI: 10.1016/j.amjms.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 08/15/2023] [Accepted: 09/01/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND Cardiovascular disease (CVD) is the leading cause of pregnancy-related mortality in the United States. Physiologic stress of pregnancy can induce several hemodynamic changes that contribute to an increased risk of cardiac complications in the peripartum period. There are ongoing efforts to improve cardiovascular mortality in pregnant patients. Understanding trends in cardiovascular complications during pregnancy may provide insight into improving care for high-risk pregnancies. METHODS We retrospectively analyzed data from the National Inpatient Sample (NIS) Database and identified all inpatient hospitalizations for pregnancy and delivery. We then analyzed trends in the rates of cardiac complications in the pregnant patient. RESULTS There are concerning increases in trends of cardiac complications and comorbidities in pregnant people including: acute coronary syndrome, spontaneous coronary artery dissection, cardiogenic shock, pulmonary hypertension, chronic congestive heart failure, heart transplant, aortic syndromes, stroke, and pulmonary embolism. While the rates of STEMI have decreased, the incidence of peripartum cardiomyopathy has remained stable. CONCLUSION There are concerning increases in certain cardiac complications during pregnancy. This is likely due to increasing age at the time of pregnancy and associated comorbidities.
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Affiliation(s)
- Eric D Warner
- Department of Internal Medicine, Thomas Jefferson University, Philadelphia, PA, USA.
| | - Saaniya Farhan
- Department of Internal Medicine, Thomas Jefferson University, Philadelphia, PA, USA
| | - Matthew Bierowski
- Department of Internal Medicine, Thomas Jefferson University, Philadelphia, PA, USA
| | - Farhan Sahawneh
- Drexel University College of Medicine, Philadelphia, PA, USA
| | - Estefania Oliveros
- Division of Cardiology, Temple University Hospital, Philadelphia, PA, USA
| | | | | | - Bhavadharini Ramu
- Division of Cardiology, Medical University of South Carolina, Charleston, SC, USA
| | - Waqas Ullah
- Division of Cardiology, Thomas Jefferson University, Philadelphia, PA, USA
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6
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Jose T, Maiti G, Gupta S, Kundu P. Early-onset peri-partum cardiomyopathy in a twin gestation: A rare presentation. Med J Armed Forces India 2023; 79:348-351. [PMID: 37193526 PMCID: PMC10182283 DOI: 10.1016/j.mjafi.2021.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 05/14/2021] [Indexed: 11/24/2022] Open
Abstract
Peripartum cardiomyopathy (PPCM) is a rare pregnancy-associated dilated cardiomyopathy occurring in the last month of pregnancy and five months postdelivery, which presents with features of cardiac failure. Diagnosis is based on characteristic echocardiographic findings and elevated cardiac biomarkers and has significant mortality and morbidity when undiagnosed and untreated. Atypical presentations in earlier gestations are rare and associated with risk factors. Here we present a case of PPCM diagnosed in the second trimester in a post in vitro fertilization (IVF) twin pregnancy to emphasize the importance of considering the diagnosis of PPCM in all cases of unexplained cardiac failures during pregnancy in previously healthy patients, especially in the presence of risk factors.
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Affiliation(s)
- Tony Jose
- Senior Advisor & Gynaec Oncologist, Professor & Head (Obst & Gynaec), Command Hospital (Southern Command), Pune, India
| | - G.D. Maiti
- Consultant & Head (Obst & Gynaec), INHS Asvini, Colaba, Mumbai, India
| | - Shilpa Gupta
- Classified Specialist (Obst & Gynaec), Command Hospital (Eastern Command), Kolkata, India
| | - Payel Kundu
- Resident (Obst & Gynaec), Command Hospital (Eastern Command), Kolkata, India
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7
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Koziol KJ, Aronow WS. Peripartum Cardiomyopathy: Current Understanding of Pathophysiology, Diagnostic Workup, Management, and Outcomes. Curr Probl Cardiol 2023; 48:101716. [PMID: 36972860 DOI: 10.1016/j.cpcardiol.2023.101716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 03/21/2023] [Indexed: 03/29/2023]
Abstract
Peripartum cardiomyopathy (PPCM) is a relatively rare, potentially life-threatening, idiopathic form of cardiomyopathy that affects previously healthy young women during late pregnancy or in the early postpartum period and is characterized by left ventricular (LV) systolic dysfunction in the absence of any other identifiable cardiac causes. Morbidity and mortality with PPCM are remarkably high and it continues to be one of the leading causes of maternal death. Although remarkable advances have been made in our understanding of PPCM in the last few decades, unanswered questions remain regarding its pathophysiology, diagnostic workup, and management options. In this article, we will complete an updated, comprehensive review of PPCM, including the epidemiology and risk factors, proposed etiology, presentation and complications, management, prognostic indicators and outcomes. In addition, we will identify current challenges and gaps in knowledge.
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Affiliation(s)
- Klaudia J Koziol
- New York Medical College, School of Medicine, Valhalla, New York.
| | - Wilbert S Aronow
- New York Medical College, School of Medicine, Valhalla, New York; Department of Cardiology, Westchester Medical Center, Valhalla, NY.
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8
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Carlson S, Schultz J, Ramu B, Davis MB. Peripartum Cardiomyopathy: Risks Diagnosis and Management. J Multidiscip Healthc 2023; 16:1249-1258. [PMID: 37163197 PMCID: PMC10164389 DOI: 10.2147/jmdh.s372747] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 04/27/2023] [Indexed: 05/11/2023] Open
Abstract
Peripartum cardiomyopathy is a rare cause of heart failure that occurs during late pregnancy or in the early postpartum period. Delays in diagnosis may occur as symptoms of heart failure mimic those of normal pregnancy. The diagnosis should be considered in any pregnant or postpartum woman with symptoms concerning for heart failure. If there are clinical concerns, labs including N-terminal pro-BNP should be checked, and an echocardiogram should be ordered to assess for systolic dysfunction. Prompt medical treatment tailored for pregnancy and lactation is essential to prevent adverse events. Outcomes are variable, including complete recovery, persistent myocardial dysfunction with heart failure symptoms, arrhythmias, thromboembolic events, and/or rapid deterioration requiring mechanical circulatory support and cardiac transplantation. It is essential that care is provided as part of a multidisciplinary cardio-obstetrics team including obstetrics, cardiology, maternal fetal medicine, anesthesiology, and nursing. All women with peripartum cardiomyopathy should have close follow-up with a cardiologist, although optimal duration of medical therapy following complete recovery is unknown. Women considering a subsequent pregnancy require preconception counseling and close collaboration between obstetrics and cardiology throughout pregnancy.
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Affiliation(s)
- Selma Carlson
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
- Division of Cardiology, Minneapolis VA Medical Center, Minneapolis, MN, USA
- Correspondence: Selma Carlson, Division of Cardiology, Department of Medicine, Minneapolis VA Health Care System, Minneapolis, MN, USA, Email
| | - Jessica Schultz
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Bhavadharini Ramu
- Division of Cardiology, Department of Medicine, Medical University of South Carolina (MUSC), Charleston, SC, USA
| | - Melinda B Davis
- Division of Cardiovascular Medicine, Department of Medicine, University of Michigan, Ann Arbor, MI, USA
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9
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Baltaji S, Noronha SF, Patel S, Kaura A. Obstetric Emergencies. Crit Care Nurs Q 2023; 46:66-81. [PMID: 36415068 DOI: 10.1097/cnq.0000000000000438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Human gestation and birthing result in many deviations from usual physiology that are nonetheless normal to be seen. However, on occasion, certain complications in the obstetric patient can be life-threatening to both mother and fetus. Timely recognition of these disorders and allocation of the appropriate resources are especially important. These conditions often require an intensive care unit admission for closer monitoring and supportive care. They can affect an array of physiological systems and can lead to significant morbidity. Such complications are discussed in greater detail in this article.
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Affiliation(s)
- Stephanie Baltaji
- Division of Pulmonary and Critical Care Medicine, Allegheny Health Network, Pittsburgh, Pennsylvania (Drs Baltaji and Patel); and Division of Pulmonary and Critical Care Medicine, West Penn Hospital, Pittsburgh, Pennsylvania (Drs Noronha and Kaura)
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10
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Vogel TCE, Schneiter S, Fehr T. Peripartum cardiomyopathy: a rare cause of acute heart failure. BMJ Case Rep 2022; 15:e244821. [PMID: 36351676 PMCID: PMC9644296 DOI: 10.1136/bcr-2021-244821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
A woman in her early 30s presented herself with acute dyspnoea and elevated D-dimers 5 weeks after delivery of her second child. Echocardiographic findings showed signs of acute left ventricular failure, and an MRI confirmed a non-ischaemic dilated left heart failure compatible with peripartum cardiomyopathy. The antihormonal therapy with bromocriptine during 6 weeks and an intensive heart failure therapy led to an amelioration of the heart function within 3 years, but full recovery was not yet observed.
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Affiliation(s)
| | - Stephan Schneiter
- Department of Internal Medicine, Cardiology, Kantonsspital Graubunden, Chur, Switzerland
| | - Thomas Fehr
- Department of Internal Medicine, Kantonsspital Graubunden, Chur, Switzerland
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11
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Chen PC, Chueh HY, You SH. Clinical outcomes and maternal associated conditions between antepartum and postpartum-onset of peripartum cardiomyopathy. Taiwan J Obstet Gynecol 2022; 61:999-1003. [DOI: 10.1016/j.tjog.2022.03.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2022] [Indexed: 11/23/2022] Open
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12
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Obstetric Disorders and Critical Illness. Clin Chest Med 2022; 43:471-488. [PMID: 36116815 DOI: 10.1016/j.ccm.2022.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
In this article, we discuss some of the more common obstetric-related conditions that can lead to critical illness and require management in an ICU. These include the hypertensive disorders of pregnancy, postpartum hemorrhage, hemolysis, elevated liver enzymes, and low platelet syndrome, acute fatty liver of pregnancy, amniotic fluid embolism, and peripartum cardiomyopathy. We also discuss pulmonary embolism and Covid-19. Despite not being specific to obstetric patients, pulmonary embolism is a common, life-threatening diagnosis in pregnancy with particular risks and management aspects. Covid-19 does not seem to occur with higher frequency in pregnant women, but it leads to higher rates of ICU admissions and mechanical ventilation in pregnant women than in their nonpregnant peers. Its prevalence during our current global pandemic makes it important to discuss in this article. We provide a basis for critical care physicians to be engaged in informed conversations and management in a multidisciplinary manner with other relevant providers in the care of critically ill pregnant and postpartum women.
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13
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Olanipekun T, Abe T, Effoe V, Egbuche O, Mather P, Echols M, Adedinsewo D. Racial and Ethnic Disparities in the Trends and Outcomes of Cardiogenic Shock Complicating Peripartum Cardiomyopathy. JAMA Netw Open 2022; 5:e2220937. [PMID: 35788668 PMCID: PMC9257562 DOI: 10.1001/jamanetworkopen.2022.20937] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Cardiogenic shock (CS) is a recognized complication of peripartum cardiomyopathy (PPCM) associated with poor prognosis. Although racial and ethnic disparities have been described in the occurrence and outcomes of PPCM, it is unclear if these disparities persist among patients with PPCM and CS. OBJECTIVES To evaluate the temporal trends in CS incidence among hospitalized patients with PPCM stratified by race and ethnicity and to investigate the racial and ethnic differences in hospital mortality, mechanical circulatory support (MCS) use, and heart transplantation (HT). DESIGN, SETTING, AND PARTICIPANTS This multicenter retrospective cohort study included hospitalized patients with PPCM complicated by CS in the US from 2005 to 2019 identified from the National Inpatient Sample (NIS). Data analysis was conducted in November 2021. EXPOSURE PPCM complicated by CS. MAIN OUTCOMES AND MEASURES The main outcome was incidence of CS in PPCM stratified by race and ethnicity. The secondary outcome was racial and ethnic differences in hospital mortality, MCS use, and HT. RESULTS Of 55 804 hospitalized patients with PPCM, 1945 patients had CS, including 947 Black patients, 236 Hispanic patients, and 702 White patients, translating to an incidence rate of 35 CS events per 1000 patients with PPCM. The mean (SD) age was 31 (9) years. Black and Hispanic patients had higher CS incidence rates (39 events per 1000 patients with PPCM) compared with White patients (33 events per 1000 patients with PPCM). CS incidence rates significantly increased across all races and ethnicities over the study period. Overall, the odds of developing CS were higher in Black patients (aOR, 1.17 [95% CI, 1.15-1.57]; P < .001) and Hispanic patients (aOR, 1.37 [95% CI, 1.17-1.59]; P < 001) compared with White patients during the study period. Compared with White patients, the odds of in-hospital mortality were higher in Black (adjusted odds ratio [aOR], 1.67 [95% CI, 1.21-2.32]; P = .002) and Hispanic (aOR, 2.20 [95% CI, 1.45-3.33]; P < .001) patients. Hispanic patients were more likely to receive any type of MCS device (aOR, 2.23 [95% CI, 1.60-3.09]; P < .001), intraaortic balloon pump (aOR, 1.65 [95% CI, 1.11-2.44]; P < .001), and ventricular assisted device (aOR, 4.45 [95% CI, 2.45-8.08]; P < .001), compared with White patients. Black patients were more likely to receive VAD (aOR, 2.69 [95% CI, 1.63-4.42]; P < .001) compared with White patients. Black and Hispanic patients were significantly less likely to receive HT compared with White patients (Black patients: aOR, 0.51 [95% CI, 0.33-0.78]; P = .02; Hispanic patients: aOR, 0.15 [95% CI, 0.06-0.42]; P < .001). CONCLUSIONS AND RELEVANCE These findings highlight significant racial disparities in mortality and HT among hospitalized patients with PPCM complicated by CS in the US. More research to identify factors of racial and ethnic disparities is needed to guide interventions to improve outcomes of patients with PPCM.
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Affiliation(s)
- Titilope Olanipekun
- Department of Hospital Medicine, Covenant Health System, Knoxville, Tennessee
- Department of Internal Medicine, Morehouse School of Medicine, Atlanta, Georgia
| | - Temidayo Abe
- Department of Internal Medicine, Morehouse School of Medicine, Atlanta, Georgia
| | - Valery Effoe
- Department of Cardiovascular Medicine, Morehouse School of Medicine, Atlanta, Georgia
| | - Obiora Egbuche
- Department of Interventional Cardiology, Ohio School of Medicine, Columbus
| | - Paul Mather
- Department of Cardiovascular Disease, Perelman School of Medicine, East Perelman Center for Advanced Medicine, University of Pennsylvania, Philadelphia
| | - Melvin Echols
- Department of Cardiovascular Medicine, Morehouse School of Medicine, Atlanta, Georgia
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14
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Imran TF, Mohebali D, Lopez D, Goli RR, DeFilippis EM, Truong S, Bello NA, Gaziano JM, Djousse L, Coglianese EE, Feinberg L, Wu WC, Choudhary G, Arany Z, Kociol R, Sabe MA. NT-proBNP and predictors of event free survival and left ventricular systolic function recovery in peripartum cardiomyopathy. Int J Cardiol 2022; 357:48-54. [PMID: 35358637 PMCID: PMC10007968 DOI: 10.1016/j.ijcard.2022.03.052] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 03/12/2022] [Accepted: 03/24/2022] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To determine predictors of adverse outcomes in peripartum cardiomyopathy (PPCM). METHODS AND RESULTS We conducted a multi-center cohort study across four centers to identify subjects with PPCM with the following criteria: LVEF <40%, development of heart failure within the last month of pregnancy or within 5 months of delivery and no other identifiable cause of heart failure with reduced ejection fraction. Outcomes included 1) survival free from major adverse events (need for extra-corporeal membrane oxygenation, ventricular assist device, orthotopic heart transplantation or death) and 2) LVEF recovery ≥ 50%. Using a univariate logistic regression analysis, we identified significant clinical predictors of these outcomes, which were then used to create multivariable models. NT-proBNP at the time of diagnosis was examined both as a continuous variable (log transformed) in logistic regression and as a dichotomous variable (values above and below the median) using the log-rank test. In all, 237 women (1993 to 2017) with 736.4 person-years of follow-up, met criteria for PPCM. Participants had a mean age of 32.4 ± 6.7 years, mean BMI 30.6 ± 7.8 kg/m2; 63% were White. After median follow-up of 3.6 years (IQR 1.1-7.8), 113 (67%) had LVEF recovery, and 222 (94%) had survival free from adverse events. Significant predictors included gestational age, gravidity, systolic blood pressure, smoking, heart rate, initial LVEF, and diuretic use. In a subset of 110 patients with measured NTproBNP levels, we found a higher event free survival for women with NTproBNP <2585 pg/ml (median) as compared to women with NTproBNP ≥2585 pg/ml (log-rank test p-value 0.018). CONCLUSION Gestational age, gravidity, current or past tobacco use, systolic blood pressure, heart rate, initial LVEF and diuretic requirement at the time of diagnosis were associated with survival free from adverse events and LVEF recovery. Initial NT-proBNP was significantly associated with event free survival.
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Affiliation(s)
- Tasnim F Imran
- Warren Alpert Medical School of Brown University, Section of Cardiology, Rhode Island and Miriam Hospitals, and Providence VA Medical Center, Providence, RI 02809, USA; Department of Medicine, Division of Aging, Brigham and Women's Hospital and the VA Boston Healthcare System, Harvard Medical School, Boston, MA 02120, USA.
| | - Donya Mohebali
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Diana Lopez
- Department of Medicine, Division of Aging, Brigham and Women's Hospital and the VA Boston Healthcare System, Harvard Medical School, Boston, MA 02120, USA
| | - Rahul R Goli
- Cardiovascular Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ersilia M DeFilippis
- Department of Medicine, Division of Aging, Brigham and Women's Hospital and the VA Boston Healthcare System, Harvard Medical School, Boston, MA 02120, USA; Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, NY, USA
| | - Sandy Truong
- Department of Medicine, Division of Aging, Brigham and Women's Hospital and the VA Boston Healthcare System, Harvard Medical School, Boston, MA 02120, USA
| | - Natalie A Bello
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, NY, USA
| | - J Michael Gaziano
- Department of Medicine, Division of Aging, Brigham and Women's Hospital and the VA Boston Healthcare System, Harvard Medical School, Boston, MA 02120, USA
| | - Luc Djousse
- Department of Medicine, Division of Aging, Brigham and Women's Hospital and the VA Boston Healthcare System, Harvard Medical School, Boston, MA 02120, USA
| | - Erin E Coglianese
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Loryn Feinberg
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Wen-Chih Wu
- Warren Alpert Medical School of Brown University, Section of Cardiology, Rhode Island and Miriam Hospitals, and Providence VA Medical Center, Providence, RI 02809, USA
| | - Gaurav Choudhary
- Warren Alpert Medical School of Brown University, Section of Cardiology, Rhode Island and Miriam Hospitals, and Providence VA Medical Center, Providence, RI 02809, USA
| | - Zoltan Arany
- Cardiovascular Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Robb Kociol
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Marwa A Sabe
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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15
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Kuć A, Kubik D, Kościelecka K, Szymanek W, Męcik-Kronenberg T. The Relationship Between Peripartum Cardiomyopathy and Preeclampsia – Pathogenesis, Diagnosis and Management. J Multidiscip Healthc 2022; 15:857-867. [PMID: 35496718 PMCID: PMC9045831 DOI: 10.2147/jmdh.s357872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 03/14/2022] [Indexed: 12/03/2022] Open
Abstract
Peripartum cardiomyopathy (PPCM) is a condition with an incompletely understood etiology, although many risk factors for this disorder have been mentioned. Preeclampsia (PE) is a rare but undoubtedly very important cause of PPCM. Early recognition and prompt treatment of preeclampsia and peripartum cardiomyopathy are essential to optimize pregnancy outcomes. An extensive manual search of major electronic databases was conducted in November 2021. The following literature review provides a comprehensive discussion of peripartum cardiomyopathy and preeclampsia and quantifies the prevalence of PE in women with PPCM. The authors highlighted aspects such as epidemiology, risk factors, cardiovascular changes, diagnosis and clinical presentation, and management and complications. Accumulating data indicate that both conditions have a similar pathogenesis characterized by vascular abnormalities. In both conditions we can observe an increase in interleukin-6 and gamma interferon, CCL2/MCP1, and decreased SOD activity. sFLT1 (a soluble form of fms-like tyrosine kinase 1), a substance with antiangiogenic and probably cardiotoxic effects, may be important. Preeclampsia and peripartum cardiomyopathy are characterized by recurrence rates that follow a similar pattern in subsequent pregnancies, and mortality remains a concern. Our analysis highlights the need to better understand the co-morbidity of PE and PPCM, and the need to qualify patients for the same clinical trials because of the common origin of these conditions.
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Affiliation(s)
- Aleksandra Kuć
- Student Research Group at the Chair and Department of Pathomorphology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Zabrze, Poland
- Correspondence: Aleksandra Kuć, 1E Street, Siedlce, 08-110, Poland, Tel +48 504 188 178, Email
| | - Daria Kubik
- Student Research Group at the Chair and Department of Pathomorphology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Zabrze, Poland
| | - Klaudia Kościelecka
- Student Research Group at the Chair and Department of Pathomorphology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Zabrze, Poland
| | - Wojciech Szymanek
- Hospital Emergency Department, St. John Paul II Mazovia Regional Hospital in Siedlce, Siedlce, Poland
- Nursing at Collegium Mazovia Innovative University in Siedlce, Siedlce, Poland
| | - Tomasz Męcik-Kronenberg
- Chair and Department of Pathomorphology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Zabrze, Poland
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16
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Ijaz SH, Jamal S, Minhas AMK, Sheikh AB, Nazir S, Khan MS, Minhas AS, Hays AG, Warraich HJ, Greene SJ, Fudim M, Honigberg MC, Khan SS, Paul TK, Michos ED. Trends in Characteristics and Outcomes of Peripartum Cardiomyopathy Hospitalizations in the United States Between 2004 and 2018. Am J Cardiol 2022; 168:142-150. [PMID: 35074213 PMCID: PMC9944609 DOI: 10.1016/j.amjcard.2021.12.034] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 12/25/2021] [Accepted: 12/28/2021] [Indexed: 12/20/2022]
Abstract
Data are limited on contemporary temporal trends in maternal characteristics and outcomes in hospitalized patients with peripartum cardiomyopathy (PC). We used the National Inpatient Sample database from January 1, 2004, to December 31, 2018, to identify PC hospitalizations in women aged 15 to 54 years. Weighted survey data were used to derive national estimates for the United States population and examine trends. Between 2004 and 2018, there was a total of 23,420 weighted hospitalizations for PC in women aged 15 to 54 years. The mean (standard error) age of this hospitalized PC population was 30.3 (0.1) years, with 44.6% White, 39.3% Black, 9.0% Hispanics, and 7.1% "Other" racial/ethnic groups. There was a nonsignificant increase in the PC hospitalization per 100,000 live births from 33.6 in 2004 to 42.4 in 2018 (p-trend = 0.06) over the study period, driven by a statistically significant increase in the younger women age group 15 to 35 years (p-trend = 0.04). The PC hospitalizations per 100,000 live births for women aged 36 to 54 years were more than double that observed in women aged 15 to 35 years (77.6 vs 33.5). PC hospitalizations were more than threefold greater in Black versus White women (103.5 vs 32.0 per 100,000 live births). Overall, inpatient mortality was 0.8%; the adjusted inpatient mortality showed a nonsignificant overall decrease from 1.1% in 2004 to 0.5% in 2018 (p-trend = 0.15). The overall mean length of stay was 4.6 days; the adjusted mean length of stay decreased from 5.8 days in 2004 to 4.6 days in 2018 (p-trend <0.01). In conclusion, there has been a nonsignificant increase in hospitalizations for PC, driven by an increasing rate of hospitalizations in younger women. The older maternal age group and Black patients had a higher proportional hospitalization as compared with the younger age group and White patients. There was a nonsignificant decrease in inpatient mortality.
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Affiliation(s)
- Sardar Hassan Ijaz
- Division of Cardiology, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Shakeel Jamal
- College of Medicine, Central Michigan University, Saginaw, Michigan
| | | | - Abu Baker Sheikh
- Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Salik Nazir
- Division of Cardiovascular Medicine, University of Toledo Medical Center, Toledo, Ohio
| | | | - Anum S. Minhas
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Allison G. Hays
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Haider J. Warraich
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Stephen J. Greene
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina,Duke Clinical Research Institute, Durham, North Carolina
| | - Marat Fudim
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina,Duke Clinical Research Institute, Durham, North Carolina
| | | | - Sadiya S. Khan
- Division of Cardiology, Department of Medicine,Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Timir K. Paul
- Division of Cardiology, East Tennessee State University, Johnson City, Tennessee
| | - Erin D. Michos
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
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17
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Akgoz H, Gurkan U. Subclinical myocardial dysfunction in patients with complete recovery from peripartum cardiomyopathy: a long-term clinical strain-echocardiographic study. Hypertens Pregnancy 2022; 41:89-96. [DOI: 10.1080/10641955.2022.2046049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Haldun Akgoz
- Cardiology Department, Acıbadem Kadıkoy Hospital, Istanbul, Turkey
| | - Ufuk Gurkan
- Cardiology Department, Siyami Ersek Thoracic and Cardiovascular Surgery Center, İstanbul, Turkey
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18
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Lee YJ, Choi B, Lee MS, Jin U, Yoon S, Jo YY, Kwon JM. An artificial intelligence electrocardiogram analysis for detecting cardiomyopathy in the peripartum period. Int J Cardiol 2022; 352:72-77. [PMID: 35122911 DOI: 10.1016/j.ijcard.2022.01.064] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 01/19/2022] [Accepted: 01/28/2022] [Indexed: 01/08/2023]
Abstract
BACKGROUND Peripartum cardiomyopathy (PPCM) is a fatal maternal complication, with left ventricular systolic dysfunction (LVSD; Left ventricular ejection fraction 45% or less) occurring at the end of pregnancy or in the months following delivery. The scarcity of screening tools for PPCM leads to a delayed diagnosis and increases its mortality and morbidity. We aim to evaluate an electrocardiogram (ECG)-deep learning model (DLM) for detecting cardiomyopathy in the peripartum period. METHODS For the DLM development and internal performance test for detecting LVSD, we obtained a dataset of 122,733 ECG-echocardiography pairs from 58,530 male and female patients from two community hospitals. For the DLM external validation, this study included 271 ECG-echocardiography pairs (157 unique pregnant and postpartum period women) examined in the Ajou University Medical Center (AUMC) between January 2007 and May 2020. All included cases underwent an ECG within two weeks before or after the day of transthoracic echocardiography, which was performed within a month before delivery, or within five months after delivery. Based on the diagnostic criteria of PPCM, we analyzed the area under the receiver operating characteristic curve (AUROC), sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) to evaluate the model effectiveness. RESULTS The ECG-based DLM detected PPCM with an AUROC of 0.877. Moreover, its sensitivity, specificity, PPV, and NPV for the detection of PPCM were 0.877, 0.833, 0.809, 0.352, and 0.975, respectively. CONCLUSIONS An ECG-based DLM non-invasively and effectively detects cardiomyopathies occurring in the peripartum period and could be an ideal screening tool for PPCM.
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Affiliation(s)
- Ye Ji Lee
- Department of Obstetrics and Gynecology, Gangdong Miz Women's Hospital, Seoul, Republic of Korea
| | - Byungjin Choi
- Department of Biomedical Informatics, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Min Sung Lee
- Medical research team, Medical AI, Seoul, Republic of Korea.
| | - Uram Jin
- Department of Cardiology, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Seokyoung Yoon
- Ajou University School of Medicine, Department of Obstetrics and Gynecology, Republic of Korea
| | - Yong-Yeon Jo
- Medical research team, Medical AI, Seoul, Republic of Korea
| | - Joon-Myoung Kwon
- Medical research team, Medical AI, Seoul, Republic of Korea; Department of Emergency Medicine, Mediplex Sejong Hospital, Incheon, Republic of Korea.; Artificial Intelligence and Big Data Research Center, Sejong Medical Research Institute, Bucheon, Republic of Korea
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19
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Abstract
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.
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20
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Kwon JH, Tedford RJ, Ramu B, Witer LJ, Pope NH, Houston BA, Hashmi ZA, Katz MR, Kilic A. Heart Transplantation for Peripartum Cardiomyopathy: Outcomes over Three Decades. Ann Thorac Surg 2022; 114:650-658. [DOI: 10.1016/j.athoracsur.2021.12.059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 12/09/2021] [Accepted: 12/16/2021] [Indexed: 11/29/2022]
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21
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Himmelwright RS, Dominguez JE. Postpartum Respiratory Depression. Anesthesiol Clin 2021; 39:687-709. [PMID: 34776104 DOI: 10.1016/j.anclin.2021.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Postpartum respiratory depression is a complex, multifactorial issue that encompasses a patient's baseline preexisting conditions, certain pregnancy-specific conditions or complications, as well as the iatrogenic element of various medications given in the peripartum period. In this review, we discuss many of these factors including obesity, sleep-disordered breathing, chronic lung disease, neuromuscular disorders, opioids, preeclampsia, peripartum cardiomyopathy, postpartum hemorrhage, amniotic fluid embolism, sepsis, acute respiratory distress syndrome (ARDS), and medications such as analgesics, sedatives, anesthetics, and magnesium. Current recommendations for screening, treatment, and prevention are also discussed.
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Affiliation(s)
| | - Jennifer E Dominguez
- Duke University Medical Center, DUMC 3094, MS#9, 2301 Erwin Road, Durham, NC 27710, USA.
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22
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Abstract
Importance Peripartum cardiomyopathy is a rare form of heart failure due to left ventricular systolic dysfunction that affects women late in pregnancy and the postpartum period. A diagnosis of exclusion, peripartum cardiomyopathy can be difficult to diagnose in the context of the normal physiologic changes of pregnancy and requires a high index of suspicion. Evidence Acquisition Original research articles, review articles, and guidelines on peripartum cardiomyopathy were reviewed. Results The etiology of peripartum cardiomyopathy remains poorly defined, but theories include genetic predisposition, as well as myocardial inflammation and angiogenic dysregulation. Risk factors for this condition include hypertensive disorders of pregnancy, Black race, and maternal age older than 30 years. Patients with peripartum cardiomyopathy are at increased risk of acute clinical decompensation, cardiac arrhythmias, thromboembolic complications, and death. Primary treatment modalities include initiation of a medication regimen aimed at the optimization of preload and reduction of afterload. Maternal clinical status is the primary determinant for timing of delivery. Conclusions Prompt diagnosis and medical management by an interdisciplinary care team are vital for improving outcomes in patients with peripartum cardiomyopathy.
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23
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Abstract
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.
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Affiliation(s)
- Erika J Douglass
- Department of Cardiovascular Medicine, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA; Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Lori A Blauwet
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
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24
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Abstract
Heart failure (HF) remains the most common major cardiovascular complication arising in pregnancy and the postpartum period. Mothers who develop HF have been shown to experience an increased risk of death as well as a variety of adverse cardiac and obstetric outcomes. Recent studies have demonstrated that the risk to neonates is significant, with increased risks in perinatal morbidity and mortality, low Apgar scores, and prolonged neonatal intensive care unit stays. Information on the causal factors of HF can be used to predict risk and understand timing of onset, mortality, and morbidity. A variety of modifiable, nonmodifiable, and obstetric risk factors as well as comorbidities are known to increase a patient's likelihood of developing HF, and there are additional elements that are known to portend a poorer prognosis beyond the HF diagnosis. Multidisciplinary cardio‐obstetric teams are becoming more prominent, and their existence will both benefit patients through direct care and increased awareness and educate clinicians and trainees on this patient population. Detection, access to care, insurance barriers to extended postpartum follow‐up, and timely patient counseling are all areas where care for these women can be improved. Further data on maternal and fetal outcomes are necessary, with the formation of State Maternal Perinatal Quality Collaboratives paving the way for such advances.
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Affiliation(s)
- Rachel A Bright
- Division of Cardiovascular Medicine Department of Medicine State University of New YorkStony Brook University Medical CenterRenaissance School of Medicine Stony Brook NY
| | - Fabio V Lima
- Division of Cardiology Warren Alpert Medical School of Brown University and Lifespan Cardiovascular Institute Providence RI
| | - Cecilia Avila
- Department of Obstetrics, Gynecology and Reproductive Medicine Stony Brook University Medical Center Stony Brook NY
| | - Javed Butler
- Department of Medicine University of Mississippi Jackson MS
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25
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Karaye KM, Ishaq NA, Sai'du H, Balarabe SA, Ahmed BG, Adamu UG, Mohammed IY, Oboirien I, Umuerri EM, Mankwe AC, Shidali VY, Dodiyi-Manuel S, Njoku P, Olunuga T, Josephs V, Mbakwem AC, Ogah OS, Tukur J, Okeahialam B, Stewart S, Henein M, Sliwa K. Disparities in clinical features and outcomes of peripartum cardiomyopathy in high versus low prevalent regions in Nigeria. ESC Heart Fail 2021; 8:3257-3267. [PMID: 34137499 PMCID: PMC8318483 DOI: 10.1002/ehf2.13463] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 04/09/2021] [Accepted: 05/23/2021] [Indexed: 12/14/2022] Open
Abstract
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.
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Affiliation(s)
- Kamilu M Karaye
- Department of Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria.,Department of Medicine, Bayero University, Kano, Nigeria.,Department of Public Health and Clinical Medicine, Umea University, Umea, Sweden.,Hatter Institute for Cardiovascular Research in Africa & CHI, Cape Town, South Africa
| | - Naser A Ishaq
- Department of Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Hadiza Sai'du
- Department of Medicine, Bayero University, Kano, Nigeria.,Department of Medicine, Murtala Mohammed Specialist Hospital, Kano, Nigeria
| | - Sulaiman A Balarabe
- Department of Medicine, Muhammad Abdullahi Wase Specialist Hospital, Kano, Nigeria
| | - Bashir G Ahmed
- Department of Medicine, Muhammad Abdullahi Wase Specialist Hospital, Kano, Nigeria
| | - Umar G Adamu
- Department of Medicine, Federal Medical Centre, Bidda, Nigeria & Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
| | - Idris Y Mohammed
- Department of Chemical Pathology, Aminu Kano Teaching Hospital, Medicine Bayero University, Kano, Nigeria
| | - Isa Oboirien
- Department of Medicine, Dalhatu Araf Specialist Hospital, Lafia, Nigeria
| | - Ejiroghene M Umuerri
- Department of Medicine, Delta State University Teaching Hospital, Oghara, Nigeria
| | - Abaram C Mankwe
- Department of Medicine, Federal medical centre, Yenagoa, Yenagoa, Nigeria
| | | | - Sotonye Dodiyi-Manuel
- Department of Medicine, University of Port Harcourt Teaching Hospital, Port Harcourt, Nigeria
| | - Paschal Njoku
- University of Nigeria Teaching Hospital, Enugu, Nigeria
| | - Taiwo Olunuga
- Department of Medicine, Federal Medical centre, Abeokuta, Nigeria
| | - Veronica Josephs
- Department of Medicine, University of Benin Teaching Hospital, Benin, Nigeria
| | - Amam C Mbakwem
- Department of Medicine, University of Lagos, Lagos, Nigeria
| | - Okechukwu S Ogah
- Department of Medicine, University College Hospital, Ibadan, Nigeria
| | - Jamilu Tukur
- Department of Obstetrics and Gynecology, Bayero University, Kano, Nigeria
| | - Basil Okeahialam
- Department of Medicine, Jos University Teaching Hospital, Jos, Nigeria
| | - Simon Stewart
- Torrens University Australia, Adelaide, South Australia, Australia
| | - Michael Henein
- Department of Public Health and Clinical Medicine, Umea University, Umea, Sweden
| | - Karen Sliwa
- Hatter Institute for Cardiovascular Research in Africa & CHI, Cape Town, South Africa
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26
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Davis MB, Jarvie J, Gambahaya E, Lindenfeld J, Kao D. Risk Prediction for Peripartum Cardiomyopathy in Delivering Mothers: A Validated Risk Model: PPCM Risk Prediction Model. J Card Fail 2021; 27:159-167. [PMID: 33388467 DOI: 10.1016/j.cardfail.2020.12.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 12/20/2020] [Accepted: 12/21/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND Peripartum cardiomyopathy (PPCM) causes significant morbidity and mortality in childbearing women. Delays in diagnosis lead to worse outcomes; however, no validated risk prediction model exists. We sought to validate a previously described model and identify novel risk factors for PPCM presenting at the time of delivery. METHODS AND RESULTS Administrative hospital records from 5,277,932 patients from 8 states were screened for PPCM, identified by International Classification of Disease-9 Clinical Modification codes (674.5x) at the time of delivery. Demographics, comorbidities, procedures, and outcomes were quantified. Performance of a previously published regression model alone and with the addition of novel PPCM-associated characteristics was assessed using receiver operating characteristic area under the curve (AUC) analysis. Novel risk factors were identified using multivariate logistic regression and the likelihood ratio test. In total, 1186 women with PPCM were studied, including 535 of 4,003,912 delivering mothers (0.013%) in the derivation set compared with 651 of 5,277,932 (0.012%) in the validation set. The previously published risk prediction model performed well in both the derivation (area under the curve 0.822) and validation datasets (area under the curve 0.802). Novel PPCM-associated characteristics in the combined cohort included diabetes mellitus (odds ratio [OR] of PPCM 1.93, 95% confidence interval [CI] 1.23-3.02, P = .004), mood disorders (OR 1.74, 95% CI 1.22-2.47, P = .002), obesity (OR 1.92, 95% CI 1.45-2.55, P < .001), and Medicaid insurance (OR 1.54, 95% CI 1.22-1.96, P < .001). CONCLUSIONS This is the first validated risk prediction model to identify women at increased risk for PPCM at the time of delivery. Diabetes mellitus, obesity, mood disorders, and lower socioeconomic status are risk factors associated with PPCM. This model may be useful for identifying women at risk and preventing delays in diagnosis.
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Affiliation(s)
| | | | | | | | - David Kao
- University of Colorado, Aurora, Colorado
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27
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Abstract
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.
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Affiliation(s)
- Nivedita Jha
- Department of Obstetrics and Gynaecology, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry, India
| | - Ajay Kumar Jha
- Cardiothoracic Division, Department of Anaesthesiology and Critical Care, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry, India.
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Ramaccini D, Montoya-Uribe V, Aan FJ, Modesti L, Potes Y, Wieckowski MR, Krga I, Glibetić M, Pinton P, Giorgi C, Matter ML. Mitochondrial Function and Dysfunction in Dilated Cardiomyopathy. Front Cell Dev Biol 2021; 8:624216. [PMID: 33511136 PMCID: PMC7835522 DOI: 10.3389/fcell.2020.624216] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 12/16/2020] [Indexed: 12/14/2022] Open
Abstract
Cardiac tissue requires a persistent production of energy in order to exert its pumping function. Therefore, the maintenance of this function relies on mitochondria that represent the “powerhouse” of all cardiac activities. Mitochondria being one of the key players for the proper functioning of the mammalian heart suggests continual regulation and organization. Mitochondria adapt to cellular energy demands via fusion-fission events and, as a proof-reading ability, undergo mitophagy in cases of abnormalities. Ca2+ fluxes play a pivotal role in regulating all mitochondrial functions, including ATP production, metabolism, oxidative stress balance and apoptosis. Communication between mitochondria and others organelles, especially the sarcoplasmic reticulum is required for optimal function. Consequently, abnormal mitochondrial activity results in decreased energy production leading to pathological conditions. In this review, we will describe how mitochondrial function or dysfunction impacts cardiac activities and the development of dilated cardiomyopathy.
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Affiliation(s)
- Daniela Ramaccini
- University of Hawaii Cancer Center, Honolulu, HI, United States.,Department of Medical Sciences, University of Ferrara, Ferrara, Italy.,Laboratory of Technologies for Advanced Therapy (LTTA), Technopole of Ferrara, Ferrara, Italy
| | | | - Femke J Aan
- University of Hawaii Cancer Center, Honolulu, HI, United States
| | - Lorenzo Modesti
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy.,Laboratory of Technologies for Advanced Therapy (LTTA), Technopole of Ferrara, Ferrara, Italy
| | - Yaiza Potes
- Laboratory of Mitochondrial Biology and Metabolism, Nencki Institute of Experimental Biology of Polish Academy of Sciences, Warsaw, Poland
| | - Mariusz R Wieckowski
- Laboratory of Mitochondrial Biology and Metabolism, Nencki Institute of Experimental Biology of Polish Academy of Sciences, Warsaw, Poland
| | - Irena Krga
- Center of Research Excellence in Nutrition and Metabolism, Institute for Medical Research, University of Belgrade, Belgrade, Serbia
| | - Marija Glibetić
- Center of Research Excellence in Nutrition and Metabolism, Institute for Medical Research, University of Belgrade, Belgrade, Serbia
| | - Paolo Pinton
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy.,Laboratory of Technologies for Advanced Therapy (LTTA), Technopole of Ferrara, Ferrara, Italy.,Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | - Carlotta Giorgi
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy.,Laboratory of Technologies for Advanced Therapy (LTTA), Technopole of Ferrara, Ferrara, Italy
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Douglass EJ, Cooper LT, Morales-Lara AC, Adedinsewo DA, Rozen TD, Blauwet LA, Fairweather D. A Case-Control Study of Peripartum Cardiomyopathy Using the Rochester Epidemiology Project. J Card Fail 2021; 27:132-142. [PMID: 33388468 PMCID: PMC8781686 DOI: 10.1016/j.cardfail.2020.12.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 12/12/2020] [Accepted: 12/21/2020] [Indexed: 12/26/2022]
Abstract
Background: The incidence of peripartum cardiomyopathy (PPCM) is known through referral center databases that may be affected by referral, misclassification, and other biases. We sought to determine the community-based incidence and natural history of PPCM using the Rochester Epidemiology Project. Methods and Results: Incident cases of PPCM occurring between January 1, 1970, and December 31, 2014, were identified in Olmsted County, Minnesota. A total of 15 PPCM cases were confirmed yielding an incidence of 20.3 cases per 100,000 live births in Olmsted County, Minnesota. Clinical information, disease characteristics, and outcomes were extracted from medical records in a 27-county region of the Rochester Epidemiology Project including Olmsted County and matched in a 1:2 ratio with pregnant women without PPCM. A total of 48 women were identified with PPCM in the expanded 27-county region. There was 1 death and no transplants over a median of 7.3 years of follow-up. Six of the 23 women with subsequent pregnancies developed recurrent PPCM, all of whom recovered. Migraine and anxiety were identified as novel possible risk factors for PPCM. Conclusions: The population-based incidence of PPCM was 20.3 cases per 100,000 live births in Olmsted County, Minnesota. Cardiovascular outcomes were generally excellent in this community cohort.
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Affiliation(s)
- Erika J Douglass
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, Florida; Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Leslie T Cooper
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, Florida
| | | | | | - Todd D Rozen
- Department of Neurology, Mayo Clinic, Jacksonville, Florida
| | - Lori A Blauwet
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Delisa Fairweather
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, Florida; Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.
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30
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Mahmoudi E, Tabary M, Khaheshi I. Pulmonary thromboembolism presenting with chest pain in a case of peripartum cardiomyopathy. Future Cardiol 2020; 16:263-269. [PMID: 32180452 DOI: 10.2217/fca-2019-0029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Peripartum cardiomyopathy (PPCM) is an idiopathic reduction in left ventricular function, presenting at the peripartum period. The diagnosis is based on echocardiographic features and excluding other causes of heart failure. Similar to any other cause of heart failure, the management of PPCM consists of diuretics, prevention of ventricular remodeling, preventing short and long-term complications. Ventricular clots, transient cerebral ischemic attacks, lower extremity thrombosis, kidney and liver infarcts and pulmonary thromboembolism have been previously reported in PPCM cases. Among them, pulmonary thromboembolism is one of the most important complications, as it is also a challenging differential diagnosis of PPCM. We discuss a case of PPCM followed by a diagnosis of pulmonary thromboembolism and briefly review the relevant PPCM literature.
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Affiliation(s)
- Elham Mahmoudi
- Cardiovascular Diseases Research Center, Shahid Modarres Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Isa Khaheshi
- Cardiovascular Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Abstract
Anthracycline-associated cardiomyopathy and peripartum cardiomyopathy are nonischemic cardiomyopathies that often afflict previously healthy young patients; both diseases have been well described since at least the 1970s and both occur in the settings of predictable stressors (ie, cancer treatment and pregnancy). Despite this, the precise mechanisms and the ability to reliably predict who exactly will go on to develop cardiomyopathy and heart failure in the face of anthracycline exposure or childbirth have proven elusive. For both cardiomyopathies, recent advances in basic and molecular sciences have illuminated the complex balance between cardiomyocyte and endothelial homeostasis via 3 broad pathways: reactive oxidative stress, interference in apoptosis/growth/metabolism, and angiogenic imbalance. These advances have already shown potential for specific, disease-altering therapies, and as our mechanistic knowledge continues to evolve, further clinical successes are expected to follow.
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Affiliation(s)
- Joshua A Cowgill
- From the Department of Cardiovascular Medicine, Maine Medical Center, Portland
| | - Sanjeev A Francis
- From the Department of Cardiovascular Medicine, Maine Medical Center, Portland
| | - Douglas B Sawyer
- From the Department of Cardiovascular Medicine, Maine Medical Center, Portland
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32
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Davis MB, Arany Z, McNamara DM, Goland S, Elkayam U. Peripartum Cardiomyopathy. J Am Coll Cardiol 2020; 75:207-221. [DOI: 10.1016/j.jacc.2019.11.014] [Citation(s) in RCA: 89] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 11/06/2019] [Accepted: 11/13/2019] [Indexed: 01/13/2023]
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Rana KF, Saeed A, Shamim SA, Tariq MA, Malik BH. The Association between Hypertensive Disorders of Pregnancy and Peripartum Cardiomyopathy. Cureus 2019; 11:e5867. [PMID: 31763090 PMCID: PMC6834093 DOI: 10.7759/cureus.5867] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Peripartum cardiomyopathy (PPCM) is a diagnosis of exclusion and a heterogeneous disorder that presents during the last month of pregnancy or the first five months postpartum. It is a rare but potentially life-threatening illness. A lot of work has been done trying to discover the causes of this condition, and several risk factors have been identified, including hypertension during pregnancy (HDP), ethnicity, advanced age, and multiple gestations. HDP affects 40% of cases of PPCM, and the strength of the association increases with increasing severity of hypertension. Among PPCM patients, there is a 1.5 times higher prevalence of HDP and a four-fold higher prevalence of preeclampsia (PE). Besides, the risk of PPCM markedly increases among women with HDP (5-21 times) compared with normotensive women. The experimental work done in animal models has provided support for the angiogenic-imbalance theory proposed regarding the association between these two conditions. The presence of the same risk factors also supports the prevalence of the coexistence of PE and PPCM. During the last part of gestation, the placenta secretes more anti-angiogenic factors, which leads to the development of both PE and PPCM. However, not all patients with HDP develop PPCM. In fact, most PPCM patients do not show any signs of HDP. Further work in these patients elucidated that there is an underlying susceptibility in some women that predisposes them to develop this condition and results in a worse prognosis as compared with those PPCM patients who have HDP. Better provision of care, genetic variations, and association with HDP have been cited as some of the factors affecting prognosis. HDP has also been found to increase the risk of other forms of cardiomyopathies in the future. A lot of work still needs to be done to uncover all the pathologic mechanisms and genetic variations involved in this disorder. More intensive and focussed research may help in developing new therapies to better manage this condition and address all of its complications.
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Affiliation(s)
- Kiran F Rana
- Family Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Aisha Saeed
- Family Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Sohaib A Shamim
- Neurology, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Muhammad Ali Tariq
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Bilal Haider Malik
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
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Abstract
PURPOSE OF REVIEW Peripartum cardiomyopathy (PPCM) is an important condition with high morbidity and mortality worldwide. Patients with PPCM are at risk of developing life-long cardiac disease, requiring regular management and medical intervention. This article conducts a review of recent literature and gives insight into this disease. RECENT FINDINGS There is promising research in the fields of vascular, hormonal and genetics. A number of genetic markers are being analyzed; including TTNC1, TTN and STAT3. Mutations to these genes have been found to be prevalent in PPCM. These combined with the secretion of placental angiogenic factors potentially create imbalance in angiogenesis as the primary etiology. SUMMARY Current biomarkers do not differentiate between PPCM and other variants of heart failure. Women with PPCM are more likely to have a cesarean section, have hypertensive disease, at greater risk of major adverse cardiac events and to have lifelong morbidity.
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Affiliation(s)
- Lindsay C Ballard
- Department of Emergency Medicine, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Rd, Portland, Oregon 97239-3098
| | - Adrian Cois
- School of Medicine, University of Notre Dame, 32 Mouat St, Fremantle WA 6160, Australia
| | - Bory Kea
- Department of Emergency Medicine, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Rd MC CR114, Portland, Oregon 97239-3098
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Lee S, Cho GJ, Park GU, Kim LY, Lee TS, Kim DY, Choi SW, Youn JC, Han SW, Ryu KH, Na JO, Choi CU, Seo HS, Kim EJ. Incidence, Risk Factors, and Clinical Characteristics of Peripartum Cardiomyopathy in South Korea. Circ Heart Fail 2019; 11:e004134. [PMID: 29626099 DOI: 10.1161/circheartfailure.117.004134] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 02/26/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Peripartum cardiomyopathy (PPCM) is a rare disorder associated with pregnancy that can lead to life-threatening conditions. The incidence and clinical characteristics of this condition remain poorly understood. METHODS AND RESULTS We aimed to perform the first population-based study of PPCM in South Korea, using the Korea National Health Insurance Claims Database of the Health Insurance Review and Assessment Service. Patients who fulfilled predefined diagnostic criteria for PPCM from January 1, 2010, to December 31, 2012, were identified from International Classification of Diseases, Tenth Revision, Clinical Modification codes. To discriminate PPCM from other causes of heart failure, we excluded subjects who already had heart failure-related International Classification of Diseases, Tenth Revision, Clinical Modification codes at least 1 year before delivery. During the study period, there were 1 404 551 deliveries in South Korea, and we excluded 20 159 patients who already had heart failure. In those, a total of 795 cases were identified as PPCM. Patients with PPCM were older, had a higher prevalence of preeclampsia and gestational diabetes mellitus, and were more likely to be primiparous and have multiple pregnancies. Moreover, cesarean section and pregnancy-related complications and in-hospital death were also more common in patients with PPCM. Intriguingly, a considerable number of heart failure cases (n=64; 8.1% of total PPCM) were noted between 5 and 12 months after delivery. CONCLUSIONS The incidence of PPCM was 1 in 1741 deliveries in South Korea. Patients with PPCM were older, were more associated with primiparity and multiple pregnancy, had more pregnancy-related complications, and revealed higher in-hospital mortality than controls. The number of cases diagnosed as PPCM were decreased over time after delivery; however, a large number of patients were still noted through 12 months after delivery.
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Affiliation(s)
- Sunki Lee
- Division of Cardiology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, South Korea (S.L., D.Y.K., S.-W.C., J.-C.Y., S.W.H., K.-H.R.). Department of Obstetrics and Gynecology (G.J.C.) and Department of Cardiology (J.O.N., C.U.C., H.S.S., E.J.K.), Korea University Guro Hospital, Seoul, South Korea. Department of Applied Statistics, Chung-Ang University, Seoul, South Korea (G.U.P.). Healthcare Data Convergence Department, Health Insurance Review and Assessment Service, Seoul, South Korea (L.Y.K., T.-S.L.)
| | - Geum Joon Cho
- Division of Cardiology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, South Korea (S.L., D.Y.K., S.-W.C., J.-C.Y., S.W.H., K.-H.R.). Department of Obstetrics and Gynecology (G.J.C.) and Department of Cardiology (J.O.N., C.U.C., H.S.S., E.J.K.), Korea University Guro Hospital, Seoul, South Korea. Department of Applied Statistics, Chung-Ang University, Seoul, South Korea (G.U.P.). Healthcare Data Convergence Department, Health Insurance Review and Assessment Service, Seoul, South Korea (L.Y.K., T.-S.L.)
| | - Geun U Park
- Division of Cardiology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, South Korea (S.L., D.Y.K., S.-W.C., J.-C.Y., S.W.H., K.-H.R.). Department of Obstetrics and Gynecology (G.J.C.) and Department of Cardiology (J.O.N., C.U.C., H.S.S., E.J.K.), Korea University Guro Hospital, Seoul, South Korea. Department of Applied Statistics, Chung-Ang University, Seoul, South Korea (G.U.P.). Healthcare Data Convergence Department, Health Insurance Review and Assessment Service, Seoul, South Korea (L.Y.K., T.-S.L.)
| | - Log Young Kim
- Division of Cardiology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, South Korea (S.L., D.Y.K., S.-W.C., J.-C.Y., S.W.H., K.-H.R.). Department of Obstetrics and Gynecology (G.J.C.) and Department of Cardiology (J.O.N., C.U.C., H.S.S., E.J.K.), Korea University Guro Hospital, Seoul, South Korea. Department of Applied Statistics, Chung-Ang University, Seoul, South Korea (G.U.P.). Healthcare Data Convergence Department, Health Insurance Review and Assessment Service, Seoul, South Korea (L.Y.K., T.-S.L.)
| | - Tae-Seon Lee
- Division of Cardiology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, South Korea (S.L., D.Y.K., S.-W.C., J.-C.Y., S.W.H., K.-H.R.). Department of Obstetrics and Gynecology (G.J.C.) and Department of Cardiology (J.O.N., C.U.C., H.S.S., E.J.K.), Korea University Guro Hospital, Seoul, South Korea. Department of Applied Statistics, Chung-Ang University, Seoul, South Korea (G.U.P.). Healthcare Data Convergence Department, Health Insurance Review and Assessment Service, Seoul, South Korea (L.Y.K., T.-S.L.)
| | - Do Young Kim
- Division of Cardiology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, South Korea (S.L., D.Y.K., S.-W.C., J.-C.Y., S.W.H., K.-H.R.). Department of Obstetrics and Gynecology (G.J.C.) and Department of Cardiology (J.O.N., C.U.C., H.S.S., E.J.K.), Korea University Guro Hospital, Seoul, South Korea. Department of Applied Statistics, Chung-Ang University, Seoul, South Korea (G.U.P.). Healthcare Data Convergence Department, Health Insurance Review and Assessment Service, Seoul, South Korea (L.Y.K., T.-S.L.)
| | - Suk-Won Choi
- Division of Cardiology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, South Korea (S.L., D.Y.K., S.-W.C., J.-C.Y., S.W.H., K.-H.R.). Department of Obstetrics and Gynecology (G.J.C.) and Department of Cardiology (J.O.N., C.U.C., H.S.S., E.J.K.), Korea University Guro Hospital, Seoul, South Korea. Department of Applied Statistics, Chung-Ang University, Seoul, South Korea (G.U.P.). Healthcare Data Convergence Department, Health Insurance Review and Assessment Service, Seoul, South Korea (L.Y.K., T.-S.L.)
| | - Jong-Chan Youn
- Division of Cardiology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, South Korea (S.L., D.Y.K., S.-W.C., J.-C.Y., S.W.H., K.-H.R.). Department of Obstetrics and Gynecology (G.J.C.) and Department of Cardiology (J.O.N., C.U.C., H.S.S., E.J.K.), Korea University Guro Hospital, Seoul, South Korea. Department of Applied Statistics, Chung-Ang University, Seoul, South Korea (G.U.P.). Healthcare Data Convergence Department, Health Insurance Review and Assessment Service, Seoul, South Korea (L.Y.K., T.-S.L.)
| | - Seong Woo Han
- Division of Cardiology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, South Korea (S.L., D.Y.K., S.-W.C., J.-C.Y., S.W.H., K.-H.R.). Department of Obstetrics and Gynecology (G.J.C.) and Department of Cardiology (J.O.N., C.U.C., H.S.S., E.J.K.), Korea University Guro Hospital, Seoul, South Korea. Department of Applied Statistics, Chung-Ang University, Seoul, South Korea (G.U.P.). Healthcare Data Convergence Department, Health Insurance Review and Assessment Service, Seoul, South Korea (L.Y.K., T.-S.L.)
| | - Kyu-Hyung Ryu
- Division of Cardiology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, South Korea (S.L., D.Y.K., S.-W.C., J.-C.Y., S.W.H., K.-H.R.). Department of Obstetrics and Gynecology (G.J.C.) and Department of Cardiology (J.O.N., C.U.C., H.S.S., E.J.K.), Korea University Guro Hospital, Seoul, South Korea. Department of Applied Statistics, Chung-Ang University, Seoul, South Korea (G.U.P.). Healthcare Data Convergence Department, Health Insurance Review and Assessment Service, Seoul, South Korea (L.Y.K., T.-S.L.)
| | - Jin Oh Na
- Division of Cardiology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, South Korea (S.L., D.Y.K., S.-W.C., J.-C.Y., S.W.H., K.-H.R.). Department of Obstetrics and Gynecology (G.J.C.) and Department of Cardiology (J.O.N., C.U.C., H.S.S., E.J.K.), Korea University Guro Hospital, Seoul, South Korea. Department of Applied Statistics, Chung-Ang University, Seoul, South Korea (G.U.P.). Healthcare Data Convergence Department, Health Insurance Review and Assessment Service, Seoul, South Korea (L.Y.K., T.-S.L.)
| | - Cheol Ung Choi
- Division of Cardiology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, South Korea (S.L., D.Y.K., S.-W.C., J.-C.Y., S.W.H., K.-H.R.). Department of Obstetrics and Gynecology (G.J.C.) and Department of Cardiology (J.O.N., C.U.C., H.S.S., E.J.K.), Korea University Guro Hospital, Seoul, South Korea. Department of Applied Statistics, Chung-Ang University, Seoul, South Korea (G.U.P.). Healthcare Data Convergence Department, Health Insurance Review and Assessment Service, Seoul, South Korea (L.Y.K., T.-S.L.)
| | - Hong Seog Seo
- Division of Cardiology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, South Korea (S.L., D.Y.K., S.-W.C., J.-C.Y., S.W.H., K.-H.R.). Department of Obstetrics and Gynecology (G.J.C.) and Department of Cardiology (J.O.N., C.U.C., H.S.S., E.J.K.), Korea University Guro Hospital, Seoul, South Korea. Department of Applied Statistics, Chung-Ang University, Seoul, South Korea (G.U.P.). Healthcare Data Convergence Department, Health Insurance Review and Assessment Service, Seoul, South Korea (L.Y.K., T.-S.L.)
| | - Eung Ju Kim
- Division of Cardiology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, South Korea (S.L., D.Y.K., S.-W.C., J.-C.Y., S.W.H., K.-H.R.). Department of Obstetrics and Gynecology (G.J.C.) and Department of Cardiology (J.O.N., C.U.C., H.S.S., E.J.K.), Korea University Guro Hospital, Seoul, South Korea. Department of Applied Statistics, Chung-Ang University, Seoul, South Korea (G.U.P.). Healthcare Data Convergence Department, Health Insurance Review and Assessment Service, Seoul, South Korea (L.Y.K., T.-S.L.).
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Binu AJ, Rajan SJ, Rathore S, Beck M, Regi A, Thomson VS, Sathyendra S. Peripartum cardiomyopathy: An analysis of clinical profiles and outcomes from a tertiary care centre in southern India. Obstet Med 2019; 13:179-184. [PMID: 33343694 DOI: 10.1177/1753495x19851397] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 04/25/2019] [Indexed: 12/14/2022] Open
Abstract
Peripartum cardiomyopathy is a syndrome of maternal heart failure with decreased left ventricular ejection fraction affecting maternal and fetal well-being. We analysed clinical profiles and outcomes in women with peripartum cardiomyopathy enrolled retrospectively from a tertiary care centre in southern India (1 January 2008-31 December 2014). The incidence of peripartum cardiomyopathy was one case per 1541 live births. Fifty-four women with a mean age of 25.5 years and mean gestational age of 35.4 weeks were recruited; 35 were primigravidae. Maternal and fetal deaths occurred in 9.3% and 24.1% of subjects, respectively. Mild-to-moderate maternal anaemia (80-110 g/L) was associated with fetal mortality (p = 0.02). Reduced left ventricular ejection fraction (<30%, p = 0.04) and cardiogenic shock (p = 0.01) were significantly associated with adverse maternal outcomes. Forty per cent of women were followed up after 24.2 ± 17.7 months, and in these women a significant increase in left ventricular ejection fraction was seen (mean 16.4%, p < 0.01); all were asymptomatic. Peripartum cardiomyopathy with poor left ventricular ejection fraction and shock is associated with adverse maternal outcomes, while non-severe maternal anaemia predisposes to adverse fetal outcomes. Significant left ventricular ejection fraction recovery occurred on follow-up.
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Affiliation(s)
- Aditya John Binu
- Department of General Medicine, Unit - III (Obstetric Medicine), Christian Medical College, Vellore, India
| | - Sudha Jasmine Rajan
- Department of General Medicine, Unit - III (Obstetric Medicine), Christian Medical College, Vellore, India
| | - Swati Rathore
- Department of Obstetrics, Christian Medical College, Vellore, India
| | - Manisha Beck
- Department of Obstetrics, Christian Medical College, Vellore, India
| | - Annie Regi
- Department of Obstetrics, Christian Medical College, Vellore, India
| | | | - Sowmya Sathyendra
- Department of General Medicine, Unit - III (Obstetric Medicine), Christian Medical College, Vellore, India
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Isogai T, Kamiya CA. Worldwide Incidence of Peripartum Cardiomyopathy and Overall Maternal Mortality. Int Heart J 2019; 60:503-511. [DOI: 10.1536/ihj.18-729] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Toshiaki Isogai
- Department of Cardiology, Tokyo Metropolitan Tama Medical Center
| | - Chizuko A. Kamiya
- Department of Perinatology and Gynecology, National Cerebral and Cardiovascular Center
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38
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Abstract
Purpose of Review Peripartum cardiomyopathy (PPCM) is an idiopathic disorder defined as heart failure occurring in women during the last month of pregnancy and up to 5 months postpartum. In this review, we outline recent reports about the disease pathogenesis and management and highlight the use of diagnosis and prognosis biomarkers. Recent Findings Novel data strengthen the implication of endothelial function in PPCM pathogenesis. The first international registry showed that patient presentations were similar globally, with heterogeneity in patient management and outcome. Summary Despite large improvement in patient management and treatment, there is still a sub-group of women who die from PPCM or who will not recover their cardiac function. Remarkable advances in the comprehension of disease incidence, pathogenesis, and prognosis could be determined with multi-center and international registries. Clinical Trials ClinicalTrials.gov Identifier: NCT02590601
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Niola M, Paternoster M, Paciello L, Giugliano P, Maiellaro A, Feola A, Perna A, Capasso E, Graziano V, Di Lorenzo P, Buccelli C. Sudden unexpected death secondary to peripartum cardiomyopathy. GAZZETTA MEDICA ITALIANA ARCHIVIO PER LE SCIENZE MEDICHE 2019. [DOI: 10.23736/s0393-3660.18.03862-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Kerpen K, Koutrolou-Sotiropoulou P, Zhu C, Yang J, Lyon JA, Lima FV, Stergiopoulos K. Disparities in death rates in women with peripartum cardiomyopathy between advanced and developing countries: A systematic review and meta-analysis. Arch Cardiovasc Dis 2019; 112:187-198. [PMID: 30594574 DOI: 10.1016/j.acvd.2018.10.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 10/01/2018] [Accepted: 10/02/2018] [Indexed: 12/19/2022]
Abstract
There is limited information about differences in maternal deaths from peripartum cardiomyopathy (PPCM) between advanced and developing countries. To review the literature to define the global prevalence of death from PPCM, and to determine the differences in PPCM mortality rates and risk factors between advanced and developing countries. Studies in the English language reporting mortality data on patients with PPCM were included from searches of MEDLINE, Embase, CINAHL, the Cochrane Library, the Web of Science Core Collection and Scopus from 01 January 2000 to 11 May 2016. Of the 4294 articles identified, 1.07% were included. The primary outcome was death; rates of heart transplant, acute myocardial infarction, heart failure, arrhythmia, cerebrovascular events, embolism and cardiac arrest were recorded. Studies were categorized as having been conducted in advanced or developing countries. Data from 46 studies, 4925 patients and 13 countries were included. There were 22 studies from advanced countries (n=3417) and 24 from developing countries (n=1508); mean follow-up was 2.6 (range 0-8.6) years. Overall mortality prevalence was 9% (95% confidence interval [CI] 6-11%). The mortality rate in developing countries (14%, 95% CI 10-18%) was significantly higher than that in advanced countries (4%, 95% CI 2-7%). There was no difference in the prevalence of risk factors (chronic hypertension, African descent, multiple gestation and multiparity) between advanced and developing countries. Studies with a higher prevalence of women of African descent had higher death rates (correlation coefficient 0.29, 95% CI 0.13-0.52). The risk of death in women with PPCM was higher in developing countries than in advanced countries. Women of African descent had an increased risk of death.
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Affiliation(s)
- Kate Kerpen
- Division of Cardiovascular Medicine, Department of Medicine, Stony Brook University Medical Center, State University of New York, Stony Brook, Nichols road, 11794 NY, United States of America
| | | | - Chencan Zhu
- Department of Applied Mathematics and Statistics, Stony Brook University, Stony Brook, 11794 NY, USA
| | - Jie Yang
- Department of Family, Population and Preventive Medicine, Stony Brook University Medical Center, Stony Brook, 11794 NY,USA
| | - Jennifer-A Lyon
- Library Services, Children's Mercy Kansas City, 64108 Kansas City, MO, USA
| | - Fabio V Lima
- Department of Medicine, Brown University, Rhode Island Hospital, 02903 Providence, RI, USA
| | - Kathleen Stergiopoulos
- Division of Cardiovascular Medicine, Department of Medicine, Stony Brook University Medical Center, State University of New York, Stony Brook, Nichols road, 11794 NY, United States of America.
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Behrens I, Basit S, Lykke JA, Ranthe MF, Wohlfahrt J, Bundgaard H, Melbye M, Boyd HA. Hypertensive disorders of pregnancy and peripartum cardiomyopathy: A nationwide cohort study. PLoS One 2019; 14:e0211857. [PMID: 30785920 PMCID: PMC6382119 DOI: 10.1371/journal.pone.0211857] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 01/23/2019] [Indexed: 01/09/2023] Open
Abstract
Background Peripartum cardiomyopathy (PPCM) is a serious cardiac disorder occurring late in pregnancy or early in the postpartum period. We examined associations between hypertensive disorders of pregnancy (HDP: preeclampsia and gestational hypertension) and PPCM, accounting for other pregnancy-related risk factors for PPCM. Methods Using nationwide Danish register data, we constructed a cohort of all women with ≥1 live birth or stillbirth in Denmark between 1978 and 2012. Using log-linear binomial regression and generalized estimating equations, we estimated risk ratios (RRs) for PPCM associated with HDP of varying severity. Results In a cohort of 1,088,063 women with 2,078,822 eligible pregnancies, 126 women developed PPCM (39 in connection with an HDP-complicated pregnancy). The risks of PPCM were significantly higher in women with HDP-complicated pregnancies than in women with normotensive pregnancies (severe preeclampsia, RR 21.2, 95% confidence interval [CI] 12.0–37.4; moderate preeclampsia, RR 10.2, 95% CI 6.18–16.9; gestational hypertension, RR 5.16, 95% CI 2.11–12.6). The RRs for moderate preeclampsia and gestational hypertension were not significantly different from one another (p = 0.18); the RR for severe preeclampsia was significantly different from the RR for moderate preeclampsia and gestational hypertension combined (p = 0.02). Conclusions Although 70% of PPCM occurred in women with normotensive pregnancies, HDPs were associated with substantial increases in PPCM risk that depended on HDP severity. The heart’s capacity to adapt to a normal pregnancy may be exceeded in some women already susceptible to cardiac insult, contributing to PPCM. HDPs, severe preeclampsia in particular, probably represent an additional cardiac stressor during pregnancy.
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Affiliation(s)
- Ida Behrens
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
| | - Saima Basit
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
| | - Jacob A. Lykke
- Department of Obstetrics, Copenhagen University Hospital (Rigshospitalet), Copenhagen, Denmark
| | - Mattis F. Ranthe
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
| | - Jan Wohlfahrt
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
| | - Henning Bundgaard
- Unit for Inherited Cardiac Disease, The Heart Centre, Copenhagen University Hospital (Rigshospitalet), Copenhagen, Denmark
| | - Mads Melbye
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
- Department of Medicine, Stanford University Medical School, Stanford, California, United States of America
| | - Heather A. Boyd
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
- * E-mail:
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Yaranov D, Alexis JD. Heart Disease in Pregnancy: A Special Look at Peripartum Cardiomyopathy. CARDIOVASCULAR INNOVATIONS AND APPLICATIONS 2019. [DOI: 10.15212/cvia.2017.0066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
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Abstract
Peripartum cardiomyopathy (PPCM) is a rare, often dilated, cardiomyopathy with systolic dysfunction that presents in late pregnancy or, more commonly, the early postpartum period. Although the condition is prevalent worldwide, women with black ancestry seem to be at greatest risk, and the condition has a particularly high incidence in Nigeria and Haiti. Other risk factors include pre-eclampsia, advanced maternal age, and multiple gestation pregnancy. Although the complete pathophysiology of peripartum cardiomyopathy remains unclear, research over the past decade suggests the importance of vasculo-hormonal pathways in women with underlying susceptibility. At least some women with the condition harbor an underlying sarcomere gene mutation. More than half of affected women recover systolic function, although some are left with a chronic cardiomyopathy, and a minority requires mechanical support or cardiac transplantation (or both). Other potential complications include thromboembolism and arrhythmia. Currently, management entails standard treatments for heart failure with reduced ejection fraction, with attention to minimizing potential adverse effects on the fetus in women who are still pregnant. Bromocriptine is one potential disease specific treatment under investigation. In this review, we summarize the current literature on peripartum cardiomyopathy, as well as gaps in the understanding of this condition and future research directions.
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Affiliation(s)
- Michael C Honigberg
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, MA, 02114, USA
- Harvard Medical School, Boston, MA, 02115, USA
| | - Michael M Givertz
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA
- Harvard Medical School, Boston, MA, 02115, USA
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Chaudhari S, Cushen SC, Osikoya O, Jaini PA, Posey R, Mathis KW, Goulopoulou S. Mechanisms of Sex Disparities in Cardiovascular Function and Remodeling. Compr Physiol 2018; 9:375-411. [PMID: 30549017 DOI: 10.1002/cphy.c180003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Epidemiological studies demonstrate disparities between men and women in cardiovascular disease prevalence, clinical symptoms, treatments, and outcomes. Enrollment of women in clinical trials is lower than men, and experimental studies investigating molecular mechanisms and efficacy of certain therapeutics in cardiovascular disease have been primarily conducted in male animals. These practices bias data interpretation and limit the implication of research findings in female clinical populations. This review will focus on the biological origins of sex differences in cardiovascular physiology, health, and disease, with an emphasis on the sex hormones, estrogen and testosterone. First, we will briefly discuss epidemiological evidence of sex disparities in cardiovascular disease prevalence and clinical manifestation. Second, we will describe studies suggesting sexual dimorphism in normal cardiovascular function from fetal life to older age. Third, we will summarize and critically discuss the current literature regarding the molecular mechanisms underlying the effects of estrogens and androgens on cardiac and vascular physiology and the contribution of these hormones to sex differences in cardiovascular disease. Fourth, we will present cardiovascular disease risk factors that are positively associated with the female sex, and thus, contributing to increased cardiovascular risk in women. We conclude that inclusion of both men and women in the investigation of the role of estrogens and androgens in cardiovascular physiology will advance our understanding of the mechanisms underlying sex differences in cardiovascular disease. In addition, investigating the role of sex-specific factors in the development of cardiovascular disease will reduce sex and gender disparities in the treatment and diagnosis of cardiovascular disease. © 2019 American Physiological Society. Compr Physiol 9:375-411, 2019.
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Affiliation(s)
- Sarika Chaudhari
- Department of Physiology and Anatomy, University of North Texas Health Science Center, Fort Worth, Texas, USA
| | - Spencer C Cushen
- Department of Physiology and Anatomy, University of North Texas Health Science Center, Fort Worth, Texas, USA
| | - Oluwatobiloba Osikoya
- Department of Physiology and Anatomy, University of North Texas Health Science Center, Fort Worth, Texas, USA
| | - Paresh A Jaini
- Department of Physiology and Anatomy, University of North Texas Health Science Center, Fort Worth, Texas, USA
| | - Rachel Posey
- Department of Physiology and Anatomy, University of North Texas Health Science Center, Fort Worth, Texas, USA
| | - Keisa W Mathis
- Department of Physiology and Anatomy, University of North Texas Health Science Center, Fort Worth, Texas, USA
| | - Styliani Goulopoulou
- Department of Physiology and Anatomy, University of North Texas Health Science Center, Fort Worth, Texas, USA
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Abstract
Significant progress in understanding the pathophysiology of peripartum cardiomyopathy, especially hormonal and genetic mechanisms, has been made. Specific criteria should be used for diagnosis, but the disease remains a diagnosis of exclusion. Both long-term and recurrent pregnancy prognoses depend on recovery of cardiac function. Data from large registries and randomized controlled trials of evidence-based therapeutics hold promise for future improved clinical outcomes.
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Affiliation(s)
- Meredith O Cruz
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, WI 53226-3522, USA.
| | - Joan Briller
- Division of Cardiology, University of Illinois at Chicago, 840 South Wood Street, M/C 715, Chicago, IL 60612, USA; Department of Obstetrics and Gynecology, University of Illinois at Chicago, 1740 W. Taylor Street, Chicago, IL 60612, USA
| | - Judith U Hibbard
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, WI 53226-3522, USA
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Pfeffer TJ, Hilfiker-Kleiner D. Pregnancy and Heart Disease: Pregnancy-Associated Hypertension and Peripartum Cardiomyopathy. Curr Probl Cardiol 2018; 43:364-388. [DOI: 10.1016/j.cpcardiol.2017.10.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Abstract
Peripartum cardiomyopathy (PPCM) is life-threatening and its diagnosis is a challenge. We highlight the clinical characteristics and bio-markers of PPCM and the proper differential diagnosis of peripartum dyspnea to aim to make an early diagnosis available.We analyzed 262 peripartum patients with dyspnea, and summed up the final diagnosis. The clinical data of the control group and the PPCM group as well as before and after the treatment of the PPCM group were compared.In total, 147 (56%) of the perinatal patients were physiologic dyspnea of pregnancy; only 11 (4%) patients met the PPCM diagnostic criteria. Compared with the basic baseline characteristics between the PPCM group and control group, patients with PPCM had a higher heart rate, and the white blood cell, high-sensitivity C-reactive protein (hs-CRP), and B-type natriuretic peptide (BNP) levels were markedly elevated, whereas PaO2 and left ventricular ejection fraction (LVEF) were lower. The heart rate, CRP and BNP levels were lower at the follow-up compared with the pretreatment. Patients who were followed up showed significant improvements in the LVEF and New York Heart Association function class.We standardized the symptoms of dyspnea for calculating, and analyzed the diagnostic efficacy of laboratory indicators. The research highlighted that the use of echocardiography and disease-specific bio-markers may aid in the diagnosis and management.
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Masoomi R, Shah Z, Arany Z, Gupta K. Peripartum cardiomyopathy: An epidemiologic study of early and late presentations. Pregnancy Hypertens 2018; 13:273-278. [DOI: 10.1016/j.preghy.2018.06.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 06/28/2018] [Indexed: 02/06/2023]
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Asad ZUA, Maiwand M, Farah F, Dasari TW. Peripartum cardiomyopathy: A systematic review of the literature. Clin Cardiol 2018; 41:693-697. [PMID: 29749620 DOI: 10.1002/clc.22932] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 02/16/2018] [Accepted: 02/23/2018] [Indexed: 01/24/2023] Open
Abstract
Peripartum cardiomyopathy (PPCM) is a rare cause of heart failure. It is defined as cardiomyopathy that develops in the last month of pregnancy or within 5 months of the postpartum period without an identifiable cause. We conducted a systematic review of literature of prospective studies with a focus on echocardiographic and long-term clinical outcomes in PPCM. We searched MEDLINE and Embase up to October 1, 2017. Prospective studies (sample size ≥20) reporting all-cause mortality and follow-up duration of ≥1 year were included. Of the 956 studies identified, 7 met the inclusion criteria. A total of 445 patients with a mean age of 30 years (range, 27-32 years) were included. The mean follow-up duration was 41 months (range, 12-61 months). The majority of patients had New York Heart Association class III or IV symptoms at the time of diagnosis. Only 3 studies reported data on ethnicity where the majority of patients were non-Caucasian. Most of the patients (81%-93%) were on guideline-directed medical therapy, except 1 study (41%). Left ventricular ejection fraction at baseline ranged from 24% to 35% (mean, 28%) and at follow-up from 31% to 53% (mean, 44%). Recovery in systolic function was noted in 20% to 82% (mean, 50%) of patients. All-cause mortality ranged from 0% to 28% (mean, 16%). This systematic review summarizes the evidence to date on the clinical characteristics and outcomes of patients with PPCM. Multicenter registries with long-term follow-up will help shed further light on characteristics and outcomes of patients with this rare disease.
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Affiliation(s)
- Zain Ul Abideen Asad
- Zain Ul Abideen Asad, Cardiovascular Disease Fellow, University of Oklahoma Health Sciences Center, Oklahoma City
| | - Mirwais Maiwand
- Mirwais Maiwand, Resident Internal Medicine, University of Oklahoma Health Sciences Center, Oklahoma City
| | - Fahmi Farah
- Fahmi Farah, Cardiovascular Disease Fellow, University of Oklahoma Health Sciences Center, Oklahoma City
| | - Tarun W Dasari
- Tarun W. Dasari, Assistant Professor of Medicine, Cardiovascular Disease Section, University of Oklahoma Health Sciences Center, Oklahoma City
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