Depression and health behaviors in women with Peripartum Cardiomyopathy

Postpartum quality of life and mental health in women with heart disease: Integrated clinical communication and treatment

BACKGROUND

Postpartum quality of life (QoL) in women with heart disease has been neglected.

AIM

To improve clinical communication and treatment, we integrated medical data and subjective characteristics to study postpartum QoL concerns.

METHODS

The study assessed QoL 6 wk after birth using the 12-Item Short-Form Health Survey. The Edinburgh Postnatal Depression Scale, Cardiac Anxiety Questionnaire, European Heart Failure Self-Care Behavior Scale, and a self-designed questionnaire based on earlier research were also used to assess patient characteristics. Patient data were collected. Prediction models were created using multiple linear regression.

RESULTS

This retrospective study examined postpartum QoL in 105 cardiac patients. Postpartum QoL scores were lower (90.69 ± 13.82) than those of women without heart disease, with physical component scores (41.09 ± 9.91) lower than mental component scores (49.60 ± 14.87). Postpartum depression (33.3%), moderate anxiety (37.14%), pregnancy concerns (57.14%), offspring heart problems (57.14%), and life expectancy worries (48.6%) were all prevalent. No previous cardiac surgery, multiparity, higher sadness and cardiac anxiety, and fear of unfavorable pregnancy outcomes were strongly related to lower QoL (R2 = 0.525).

CONCLUSION

Postpartum QoL is linked to physical and mental health in women with heart disease. Our study emphasizes the need for healthcare workers to recognize the unique characteristics of these women while developing and implementing comprehensive management approaches during their maternity care.

Pre-pregnancy stress induces maternal vascular dysfunction during pregnancy and postpartum

An estimated 20% of women suffer from a stress-related mood disorder including depression and anxiety during and after pregnancy, making these disorders among the most common complications of pregnancy. These stress-related disorders are associated with adverse pregnancy outcomes including gestational hypertension and preeclampsia, which are associated with poor cardiometabolic health postpartum. Despite these associations, the direct impact of stress and related disorders on maternal vascular health, and contributing mechanisms, remain understudied. The aim of this study was to investigate the effect of pre-pregnancy stress on maternal vascular outcomes in a BALB/c mouse model of chronic unpredictable stress. Maternal blood pressure and ex-vivo vascular function were investigated during pregnancy and postpartum. Offspring characteristics were assessed at the end of pregnancy and postpartum. Main findings show that pre-pregnancy stress exposure increased blood pressure during mid and late pregnancy and impaired ex vivo vascular function at the end of pregnancy. These effects persisted into the postpartum period, suggesting a long-term effect of stress on maternal vascular health, which appear to be partially attributable to disruptions in nitric oxide (NO) pathway signaling. These data suggest exposure to stress and related disorders, even prior to pregnancy, can contribute to vascular complications during pregnancy and postpartum.

Serum Proteomic Analysis of Peripartum Cardiomyopathy Reveals Distinctive Dysregulation of Inflammatory and Cholesterol Metabolism Pathways

BACKGROUND

The pathophysiology of peripartum cardiomyopathy (PPCM) and its distinctive biological features remain incompletely understood. High-throughput serum proteomic profiling, a powerful tool to gain insights into the pathophysiology of diseases at a systems biology level, has never been used to investigate PPCM relative to nonischemic cardiomyopathy.

OBJECTIVES

The aim of this study was to characterize the pathophysiology of PPCM through serum proteomic analysis.

METHODS

Aptamer-based proteomic analysis (SomaScan 7K) was performed on serum samples from women with PPCM (n = 67), women with nonischemic nonperipartum cardiomyopathy (NPCM) (n = 31), and age-matched healthy peripartum and nonperipartum women (n = 10 each). Serum samples were obtained from the IPAC (Investigation of Pregnancy-Associated Cardiomyopathy) and IMAC2 (Intervention in Myocarditis and Acute Cardiomyopathy) studies.

RESULTS

Principal component analysis revealed unique clustering of each patient group (P for difference <0.001). Biological pathway analyses of differentially measured proteins in PPCM relative to NPCM, before and after normalization to pertinent healthy controls, highlighted specific dysregulation of inflammatory pathways in PPCM, including the upregulation of the cholesterol metabolism-related anti-inflammatory pathway liver-X receptor/retinoid-X receptor (LXR/RXR) (P < 0.01, Z-score 1.9-2.1). Cardiac recovery by 12 months in PPCM was associated with the downregulation of pro-inflammatory pathways and the upregulation of LXR/RXR, and an additional RXR-dependent pathway involved in the regulation of inflammation and metabolism, peroxisome proliferator-activated receptor α/RXRα signaling.

CONCLUSIONS

Serum proteomic profiling of PPCM relative to NPCM and healthy controls indicated that PPCM is a distinct disease entity characterized by the unique dysregulation of inflammation-related pathways and cholesterol metabolism-related anti-inflammatory pathways. These findings provide insight into the pathophysiology of PPCM and point to novel potential therapeutic targets.

The Fourth Trimester: a Time for Enhancing Transitions in Cardiovascular Care

Purpose of Review

The "fourth trimester" concept, defined as the first 12 weeks after delivery (and beyond), is a critical window of time for clinicians to intervene to optimize women's cardiovascular health after pregnancy. A timely and comprehensive postpartum cardiovascular assessment should be performed in all women following delivery in order to (1) follow up medical conditions present prior to conception, (2) evaluate symptoms and signs of common postpartum complications, and (3) identify risk factors and prevent future adverse cardiovascular outcomes. In this review, we aim to discuss major maternal cardiovascular risk factors such as hypertensive disorders of pregnancy, gestational diabetes mellitus, postpartum weight retention, and postpartum depression, as well as lactation as a potential protective risk modifying factor. Additionally, we will review effectiveness of outpatient interventions to enhance transitions in cardiovascular care during the fourth trimester.

Recent Findings

A seamless hand-off from obstetric to primary care, and potentially cardiology, is needed for early detection and management of hypertension, weight, glycemic control, stress and mood, and long-term cardiovascular risk. Additionally, the use of telemedicine, blood pressure self-monitoring, remote activity monitoring, and behavioral health coaches are potentially feasible modalities to augment clinic-based care for cardiovascular risk factors and weight management, but additional studies are needed to study their long-term effectiveness.

Summary

Development of a comprehensive postpartum care plan with careful consideration of each patient's risk profile and access to resources is critical to improve maternal morbidity and mortality, reduce health disparities, and achieve long-term cardiovascular health for women. Supporting postpartum well-being of women during this transition period requires a multidisciplinary approach, especially primary care engagement, and planning should start before delivery.

Exercise habits and cortisol level among women at a local Zumba club

Introduction and Aim: Cortisol has a vital role in helping the body deal with stress. It is known as the primary stress hormone. Cortisol modulates many changes in the body in response to stress, including blood glucose metabolism, fat, protein, carbohydrate metabolism into energy (gluconeogenesis), immune and anti-inflammatory response. The aim of this study was to determine the impact of Zumba exercise on cortisol levels in Zumba club participants in Indonesia.  Materials and Methods: The design of the research is observational using a cross-sectional analytic study method. The samples in this study were 25 women of productive age in the I'M Z crew Zumba club in Indonesia with a purposive amplification technique.  Results: The results showed that the subjects who routinely did Zumba exercise (? 3x a week) or who did not excercie routinely (1-2x a week) to have cortisol levels within normal limits (3.09-16.66 ug/dL). The results of this study also showed that subjects who routinely did Zumba exercise (? 3x a week) have higher cortisol mean (7.82 ± 3.50) than subjects who did not regularly exercise (1-2x a week; 6.47 ± 3.46). Conclusion: There was no significant relationship between exercise habits and cortisol levels in the research subjects.

Maternal Outcomes in Women with Peripartum Cardiomyopathy versus Age and Race-Matched Peers in an Urban US Community

Peripartum cardiomyopathy (PPCM) is idiopathic systolic congestive heart failure around pregnancy. Comparisons with matched controls are lacking. We investigated maternal characteristics and outcomes up to 12 months in a cohort admitted to Montefiore Health System in Bronx, New York 1999−2015 (n = 53 cases and n = 92 age and race-matched controls, >80% Black or Hispanic/Latina). Compared to peers, women with PPCM had more chronic hypertension (24.5% vs. 8.8%, p = 0.001), prior gestational hypertension (20.8% vs. 5.4%, p = 0.001), prior preeclampsia (17.0% vs. 3.3%, p = 0.001), familial dilated cardiomyopathy (5.7% vs. 0.0%, p = 0.04), smoking (15.1% vs. 2.2%, p = 0.001), lower summary socioeconomic scores (−4.12 (IQR −6.81, −2.13) vs. −1.62 (IQR −4.20, −0.74), p < 0.001), public insurance (67.9% vs. 29.3% p = 0.001), and frequent depressive symptoms. Women with PPCM were often admitted antepartum (34.0% vs. 18.5%, p = 0.001) and underwent Cesarean section (65.4% vs. 30.4%, p = 0.001), but had less preterm labor (27.3% vs. 51.1%, p = 0.001). Women were rarely treated with bromocriptine (3.8%), frequently underwent left ventricular assist device placement (9.4% and n = 2 with menorrhagia requiring transfusion and progesterone) or heart transplantation (3.8%), but there were no in-hospital deaths. In sum, women with PPCM had worse socioeconomic disadvantage and baseline health than matched peers. Programs addressing social determinants of health may be important for women at high risk of PPCM.

Risk factors and outcomes associated with Left Ventricular Thrombus in patients with Peripartum Cardiomyopathy: An insight from National Inpatient Sample Database

Background

: We sought to assess the prevalence and impact of left ventricular thrombus (LVT) in patients with peripartum cardiomyopathy (PPCM).

Methods

: We performed a retrospective cohort study of all admissions with PPCM as the primary diagnosis from the Nationwide Inpatient Sample database over a 11-year period. Univariate analysis of all risk factors and outcomes and multivariable logistic regression analysis of certain variables were performed and represented as odds ratio (OR) with 95% confidence interval (CI). A p value of < 0.05 was considered statistically significant. Statistical analysis was performed using epiDisplay in ‘R’ studio.

Results

: In the time frame spanning 2005 -2014, 43,986 admissions with PPCM were found which included 43,534 without LVT and 452 patients with LVT. Black race was associated with a higher incidence of LV thrombus, (p value <0.001). Comorbidities more prevalent in the LVT group were smoking, drug abuse, pregnancy induced hypertension, diabetes with complications, valvular heart disease, connective tissue disorders, coagulopathy, anemia and depression. Adverse outcomes such as congestive heart failure, arrhythmias and stroke were higher in LVT group. Conversely, Caucasian race, obesity, preeclampsia (p <0.005) were higher in those without LVT. Mean length of stay (9 vs 5 days, p <0.001), in hospital mortality (3.32% vs 1.41%, p = 0.001) and mean hospitalization charges ($85,390 vs $48,033) were higher in those with LVT. However, on multivariate logistic regression, although stroke was higher in the LVT group (adjusted OR 5.51, 95% CI, 2.2, 13.81, 5.05, p 0.002), in-hospital mortality was not significantly different between the two groups (adjusted OR 1.17, 95% CI,0.32, 4.23, p = 0.817).

Conclusion

: Our study showed that PPCM patients with LV thrombus had worse outcomes with respect to stroke, length of stay and in hospital mortality. Higher prevalence in patients with black race, complicated diabetes, peripheral vascular disease, valvular disease, coagulopathy, smoking, drug abuse, depression and psychoses calls for special attention to such high-risk groups for aggressive risk factor modification.

Peripartum Cardiomyopathy

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

Risk Prediction for Peripartum Cardiomyopathy in Delivering Mothers: A Validated Risk Model: PPCM Risk Prediction Model

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.

Factors Affecting Health-Promoting Behaviors in Patients with Cardiovascular Disease

Cardiovascular disease is the leading cause of death globally and the second most common cause of death in South Korea. Health-promoting behaviors recommended for patients with cardiovascular disease include control of diet, physical activity, cessation of smoking, medication adherence, and adherence to medical recommendations. This study aimed to determine the relationship between depression, anxiety, perception of health status, and health-promoting behavior in patients from South Korea who have suffered from cardiovascular disease. The study population comprised 161 patients at the cardiovascular center at H Hospital who were diagnosed with cardiovascular disease. Descriptive statistics and stepwise multiple regression were employed to analyze the data. Negative correlations existed between depression, perception of health status, and health-promoting behavior. By contrast, a positive correlation existed between the perception of health status and health-promoting behavior. The main factors affecting health-promoting behaviors were alcohol consumption, duration of diagnosis, perception of health status, and depression. These variables explained 15.8% of the variance. To prevent adverse cardiac events, patients who suffer from cardiovascular disease should be assessed as soon as possible to identify psychiatric symptoms, thereby developing a potential intervention aimed at decreasing negative illness consequences.

Post-Traumatic Stress, Depression, and Quality of Life in Women with Peripartum Cardiomyopathy

PURPOSE

Peripartum cardiomyopathy, a traumatic life-threatening type of heart failure, occurs in the last trimester of pregnancy or shortly after childbirth. Little is known about psychological or emotional conditions women experience with peripartum cardiomyopathy. The purpose of this study was to examine relationships among post-traumatic stress, depression, and quality of life in women with peripartum cardiomyopathy.

DESIGN AND METHODS

This cross-sectional, correlational survey study included 28 participants recruited via public notice on Facebook. Participants completed the Horowitz Impact of Events Scale, the Center for Epidemiology Scale-Depression 20, and the Ferrans & Powers Quality of Life Index-Cardiac Version-IV.

RESULTS

Post-traumatic stress correlated significantly and positively with depression (r = .809, p < .001). Post-traumatic stress and depression correlated significantly and inversely with quality of life (r = -.455, p = .015), (r = -.544, p = .003), respectively. All participants measured positive for depression. Participants with lower education scored higher on post-traumatic stress and depression, whereas those unemployed or disabled registered a lower quality of life.

CLINICAL IMPLICATIONS

Nurses, midwives, and physicians caring for women with cardiomyopathies must be vigilant for evidence of post-traumatic stress, depression, and poor quality of life. Targeted antenatal and postnatal support could be vital to emotional and psychological recovery.

Assessment of major mental disorders in a German peripartum cardiomyopathy cohort

AIMS

Peripartum cardiomyopathy (PPCM) is a heart disease affecting women during the last month of pregnancy or in the first months after delivery. The impact of the disease on mental health is largely unknown.

METHODS AND RESULTS

Major mental disorders were assessed by a structured clinical interview in 40 patients with a confirmed PPCM diagnosis, and the data were compared with published prevalence in postpartum women. Circulating biomarkers associated with mental health, such as kynurenine, serotonin, and microRNA (miR)-30e, were evaluated in PPCM and compared with matched healthy pregnancy-matched postpartum controls (PP-Ctrl). Major mental disorders were diagnosed in 65% (26/40) of the PPCM cohort. The prevalence for major depressive disorders was 4-fold, for post-traumatic stress disorder 14-fold, and for panic disorder 6-fold higher in PPCM patients compared with postpartum women without a PPCM diagnosis. Compared with PP-Ctrl, PPCM patients displayed elevated levels of serum kynurenine (P < 0.01), reduced levels of serum serotonin (P < 0.05), and elevated levels of plasma miR-30e (P < 0.05).

CONCLUSIONS

The majority of PPCM patients in the present cohort displayed mental disorders with a higher prevalence of major depressive disorders, post-traumatic stress disorder (PTBS), and panic disorder, compared with postpartum women without a PPCM diagnosis. This higher prevalence was associated with an impaired tryptophan metabolism and elevated levels of the depression-associated miR-30e, suggesting a potential predisposition for mental disorders at the time of PPCM diagnosis. Consequently, physicians should be aware of the increased risk for mental disorders in PPCM patients, and psychiatric assessment should be included in the diagnosis and management of PPCM patients.

Psychosocial Adjustment and Quality of Life in Patients With Peripartum Cardiomyopathy

BACKGROUND

Psychological distress can adversely affect heart failure prognosis, yet the immediate and ongoing challenges faced by women diagnosed with peripartum cardiomyopathy (PPCM) are not well studied.

OBJECTIVE

We examined psychological distress and quality of life in a large, national sample of patients with PPCM and evaluated whether these characteristics differ among newly diagnosed (0-1 year), short-term (2-4 years), and long-term (5-10 years) survivors.

METHODS

One hundred forty-nine patients with PPCM (mean age, 33.9 ± 5.0 years) recruited from a web-based registry completed questionnaires about generalized anxiety (Generalized Anxiety Disorder-7), cardiac anxiety (Cardiac Anxiety Questionnaire [CAQ]), health status (Medical Outcomes Study Short-Form 12 [SF-12] Health Survey), and PPCM-specific quality-of-life concerns. Group differences were evaluated using multivariate statistics with adjustments for disease severity and psychiatric history.

RESULTS

Generalized anxiety symptoms higher than the clinical cutoff were reported by 53% of patients with PPCM. Mean scores on the CAQ (1.9 ± 0.7) and CAQ subscale scores (cardiac-specific fear [2.1 ± 0.8], avoidance [1.7 ± 0.9], and heart-focused attention [1.6 ± 0.8]) were elevated in the overall sample. Psychological symptoms and quality-of-life concerns were generally similar across patients except for cardiac avoidance, which was significantly higher in newly diagnosed women after adjustments for disease severity (P = .05) and psychiatric history (P = .01). Peripartum cardiomyopathy-specific quality-of-life concerns were also prevalent; however, group differences were nonsignificant (P = .07).

CONCLUSIONS

Generalized anxiety, cardiac anxiety, and quality-of-life concerns are prevalent among patients with PPCM at all stages of recovery. Psychological issues may be an underrecognized aspect of women's recovery from PPCM.

From Bench to Bedside: Translating the Prolactin/Vasoinhibin Axis

The prolactin/vasoinhibin axis defines an endocrine system, in which prolactin (PRL) and vasoinhibins regulate blood vessel growth and function, the secretion of other hormones, inflammatory and immune processes, coagulation, and behavior. The core element of the PRL/vasoinhibin axis is the generation of vasoinhibins, which consists in the proteolytic cleavage of their precursor molecule PRL. Vasoinhibins can interact with multiple different partners to mediate their effects in various tissues and anatomical compartments, indicating their pleiotropic nature. Based on accumulating knowledge about the PRL/vasoinhibin axis, two clinical trials were initiated, in which vasoinhibin levels are the target of therapeutic interventions. One trial investigates the effect of levosulpiride, a selective dopamine D2-receptor antagonist, on retinal alterations in patients with diabetic macular edema and retinopathy. The rationale of this trial is that the levosulpiride-induced hyperprolactinemia resulting in increased retinal vasoinhibins could lead to beneficiary outcomes in terms of a vasoinhibin-mediated antagonization of diabetes-induced retinal alterations. Another trial investigated the effect of bromocriptine, a dopamine D2-receptor agonist, for the treatment of peripartum cardiomyopathy. The rationale of treatment with bromocriptine is the inhibition of vasoinhibin generation by substrate depletion to prevent detrimental effects on the myocardial microvascularization. The trial demonstrated that bromocriptine treatment was associated with a high rate of left ventricular recovery and low morbidity and mortality. Therapeutic interventions into the PRL/vasoinhibin axis bear the risk of side effects in the areas of blood coagulation, blood pressure, and alterations of the mental state.