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Jackson AM, Bauersachs J, Petrie MC, van der Meer P, Laroche C, Farhan HA, Frogoudaki A, Ibrahim B, Fouad DA, Damasceno A, Karaye K, Goland S, Maggioni AP, Briton O, Sliwa K. Outcomes at one year in women with peripartum cardiomyopathy: Findings from the ESC EORP PPCM Registry. Eur J Heart Fail 2024; 26:34-42. [PMID: 37823238 DOI: 10.1002/ejhf.3055] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 10/02/2023] [Accepted: 10/10/2023] [Indexed: 10/13/2023] Open
Abstract
AIMS There are few prospective reports of 1-year outcomes for women with peripartum cardiomyopathy (PPCM). We report findings from the European Society of Cardiology EURObservational Research Programme PPCM Registry. METHODS AND RESULTS The registry enrolled women from 51 countries from 2012 to 2018. Eligibility included: (i) a peripartum state, (ii) signs or symptoms of heart failure, (iii) left ventricular (LV) ejection fraction ≤45%, (iv) exclusion of alternative causes of heart failure. We report mortality, thromboembolism, stroke, rehospitalization, LV recovery and remodelling at 1 year. Differences between regions were compared. One-year mortality data were available in 535 (71%) women and follow-up differed across regions. At 1 year, death from any cause occurred in 8.4% of women, with regional variation (Europe 4.9%, Africa 6.5%, Asia-Pacific 9.2%, Middle East 18.9%; p < 0.001). The frequencies of thromboembolism and stroke were 6.3% and 2.5%, respectively, and were similar across regions. A total of 14.0% of women had at least one rehospitalization and 3.5% had recurrent rehospitalizations (i.e. two or more). Overall, 66.1% of women had recovery of LV function (22% between 6 months and 1 year), with a mean LV ejection fraction increase from baseline of 21.2% (±13.6). Recovery occurred most frequently in Asia-Pacific (77.5%) and least frequently in the Middle East (32.7%). There were significant regional differences in the use of heart failure pharmacotherapies. CONCLUSIONS Approximately 1 in 12 women with PPCM had died by 1 year and thromboembolism and stroke occurred in 6.3% and 2.5%, respectively. Around 1 in 7 women had been rehospitalized and, in 1 in 3, LV recovery had not occurred. PPCM is associated with substantial mortality and morbidity globally.
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Affiliation(s)
- Alice M Jackson
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Medical School Hannover, Hannover, Germany
| | - Mark C Petrie
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Peter van der Meer
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Cecile Laroche
- EURObservational Research Programme, European Society of Cardiology, Sophia Antipolis, France
| | - Hasan Ali Farhan
- Iraqi Board for Medical Specializations, Scientific Council of Cardiology, Baghdad Heart Center/Medical City, Baghdad, Iraq
| | | | - Bassem Ibrahim
- Department of Cardiology, North Cumbria University Hospital, Carlisle, UK
| | - Doaa A Fouad
- Department of Cardiology, Assiut University, Asyut, Egypt
| | | | - Kamilu Karaye
- Department of Medicine, Bayero University and Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Sorel Goland
- The Heart Institute, Kaplan Medical Center, Rehovot, Hadassah Medical School, Hebrew University, Jerusalem, Israel
| | - Aldo P Maggioni
- EURObservational Research Programme, European Society of Cardiology, Sophia Antipolis, France
- ANMCO Research Center, Heart Care Foundation, Florence, Italy
| | - Olivia Briton
- Cape Heart Institute, Faculty of Health Sciences, Department of Medicine and Cardiology University of Cape Town, Cape Town, South Africa
| | - Karen Sliwa
- Cape Heart Institute, Faculty of Health Sciences, Department of Medicine and Cardiology University of Cape Town, Cape Town, South Africa
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Pachariyanon P, Bogabathina H, Jaisingh K, Modi M, Modi K. Long-Term Outcomes of Women With Peripartum Cardiomyopathy Having Subsequent Pregnancies. J Am Coll Cardiol 2023; 82:16-26. [PMID: 37380299 DOI: 10.1016/j.jacc.2023.04.043] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 03/29/2023] [Accepted: 04/24/2023] [Indexed: 06/30/2023]
Abstract
BACKGROUND Long-term maternal outcomes of subsequent pregnancies (SSPs) in patients with peripartum cardiomyopathy (PPCM) have not been analyzed. OBJECTIVES The goal of this study was to evaluate the long-term survival of SSPs in women with PPCM. METHODS We conducted a retrospective review of 137 PPCMs in the registry. The clinical and echocardiographic findings were compared between the recovery group (RG) and nonrecovery group (NRG), defined as left ventricular ejection fraction ≥50% and <50% after an index of pregnancy, respectively. RESULTS Forty-five patients with SSPs were included with a mean age of 27.0 ± 6.1 years, 80% were of African American descent, and 75.6% from a low socioeconomic background. Thirty (66.7%) women were in the RG. Overall, SSPs were associated with a decrease in mean left ventricular ejection fraction from 45.1% ± 13.7% to 41.2% ± 14.5% (P = 0.009). At 5 years, adverse outcomes were significantly higher in the NRG compared with the RG (53.3% vs 20%; P = 0.04), driven by relapse PPCM (53.3% vs 20.0%; P = 0.03). Five-year all-cause mortality was 13.33% in the NRG compared with 3.33% in the RG (P = 0.25). At a median follow-up of 8 years, adverse outcomes and all-cause mortality rates were similar in the NRG and RG (53.3% vs 33.3% [P = 0.20] and 20% vs 20%, respectively). CONCLUSIONS Subsequent pregnancies in women with PPCM are associated with adverse events. The normalization of left ventricular function does not guarantee a favorable outcome in the SSPs.
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Affiliation(s)
- Pavida Pachariyanon
- Department of Cardiology, Louisiana State University Health, Shreveport, Louisiana, USA
| | - Hari Bogabathina
- Department of Cardiology, Louisiana State University Health, Shreveport, Louisiana, USA
| | - Keerthish Jaisingh
- Department of Cardiology, Louisiana State University Health, Shreveport, Louisiana, USA
| | - Morni Modi
- School of Medicine, Louisiana State University Health, Shreveport, Louisiana, USA
| | - Kalgi Modi
- Department of Cardiology, Louisiana State University Health, Shreveport, Louisiana, USA.
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Elkayam U. Safety of Subsequent Pregnancy After Recovery From Peripartum Cardiomyopathy. J Am Coll Cardiol 2023; 82:27-29. [PMID: 37380300 DOI: 10.1016/j.jacc.2023.04.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 04/25/2023] [Indexed: 06/30/2023]
Affiliation(s)
- Uri Elkayam
- Department of Medicine, Division of Cardiology, and the Department of Obstetrics and Gynecology, University of Southern California, Keck School of Medicine, Los Angeles, California, USA.
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Koerber D, Khan S, Kirubarajan A, Spivak A, Wine R, Matelski J, Sobel M, Harris K. Meta-Analysis of Long-Term (>1 Year) Cardiac Outcomes of Peripartum Cardiomyopathy. Am J Cardiol 2023; 194:71-77. [PMID: 36989549 DOI: 10.1016/j.amjcard.2023.01.043] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 12/19/2022] [Accepted: 01/23/2023] [Indexed: 03/31/2023]
Abstract
Peripartum cardiomyopathy is the development of heart failure toward the end of pregnancy or in the months after delivery in the absence of other attributable causes, with left ventricular systolic dysfunction and a left ventricular ejection fraction (LVEF) generally <45%. Given that patients are relatively young at the time of diagnosis, this study was performed to summarize current evidence surrounding the long-term cardiac outcomes. MEDLINE, Embase, Cochrane CENTRAL, and CINAHL were searched for original studies that reported long-term (>1 year) patient outcomes. Of the 3,144 total records identified, 62 studies involving 4,282 patients met the selection criteria. The mean LVEF was 28% at diagnosis and 47% at the time of the last follow-up. Approximately half of the patients achieved myocardial recovery (47%), most commonly defined as an LVEF >50% (n = 21). The prevalence of implantable cardioverter-defibrillator use, left ventricular assist device implantation, and heart transplantation was 12%, 7%, and 11%, respectively. The overall all-cause mortality was 9%, and despite having more cardiovascular risk factors, patients residing in high-income countries had superior outcomes, including reduced rates of mortality.
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Affiliation(s)
- Daniel Koerber
- Faculty of Medicine, University of Alberta, Edmonton, Ontario, Canada; Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Shawn Khan
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Abirami Kirubarajan
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Faculty of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Alexandra Spivak
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Rachel Wine
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - John Matelski
- Biostatistics Research Unit, University Health Network, Toronto, Ontario, Canada
| | - Mara Sobel
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Obstetrics & Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Kristin Harris
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
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Human Immunodeficiency Virus Infection-Associated Cardiomyopathy and Heart Failure. J Pers Med 2022; 12:jpm12111760. [PMID: 36573732 PMCID: PMC9695202 DOI: 10.3390/jpm12111760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 10/11/2022] [Accepted: 10/17/2022] [Indexed: 12/30/2022] Open
Abstract
The landscape of human immunodeficiency virus (HIV) epidemiology and treatment is ever-changing, with the widespread and evolving use of antiretroviral therapy (ART). With timely ART, people living with HIV (PLWH) are nearing the life expectancies and the functionality of the general population; nevertheless, the effects of HIV and ART on cardiovascular health remain under investigation. The pathophysiology of HIV-related cardiomyopathy and heart failure (HF) have historically been attributed to systemic inflammation and changes in cardiometabolic function and cardiovascular architecture. Importantly, newer evidence suggests that ART also plays a role in modulating the process of HIV-related cardiomyopathy and HF. In the short term, newer highly active ART (HAART) seems to have cardioprotective effects; however, emerging data on the long-term cardiovascular outcomes of certain HAART medications, i.e., protease inhibitors, raise concerns about the potential adverse effects of these drugs in the clinical course of HIV-related HF. As such, the traditional phenotypes of dilated cardiomyopathy and left ventricular systolic failure that are associated with HIV-related heart disease are incrementally being replaced with increasing rates of diastolic dysfunction and ischemic heart disease. Moreover, recent studies have found important links between HIV-related HF and other clinical and biochemical entities, including depression, which further complicate cardiac care for PLWH. Considering these trends in the era of ART, the traditional paradigms of HIV-related cardiomyopathy and HF are being called into question, as is the therapeutic role of interventions such as ventricular assist devices and heart transplantation. In all, the mechanisms of HIV-related myocardial damage and the optimal approaches to the prevention and the treatment of cardiomyopathy and HF in PLWH remain under investigation.
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Hoevelmann J, Engel ME, Muller E, Hohlfeld A, Böhm M, Sliwa K, Viljoen C. A global perspective on the management and outcomes of peripartum cardiomyopathy: a systematic review and meta-analysis. Eur J Heart Fail 2022; 24:1719-1736. [PMID: 35778990 DOI: 10.1002/ejhf.2603] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 06/03/2022] [Accepted: 06/25/2022] [Indexed: 11/10/2022] Open
Abstract
AIMS Peripartum cardiomyopathy (PPCM) remains a major contributor to maternal morbidity and mortality worldwide. The disease is associated with various complications occurring mainly early during its course. Reported adverse outcomes include decompensated heart failure, thromboembolic complications, arrhythmias and death. We sought to systematically and comprehensively review published literature on the management, and outcome of women with PPCM across different geographical regions and to identify possible predictors of adverse outcomes. METHODS AND RESULTS We performed a comprehensive search of relevant literature (2000 to June 2021) across a number of electronic databases. Cohort, case-control and cross-sectional studies, as well as control arms of randomised controlled trials reporting on six- and/or twelve-month outcomes of PPCM were considered eligible (PROSPERO registration: CRD42021255654). Forty-seven studies (4875 patients across 60 countries) met the inclusion criteria. Haemodynamic and echocardiographic parameters were similar across all continents. All-cause mortality was 8.0% [95% CI 5.5-10.8, I2 =79.1%) at six months and 9.8% [95% CI 6.2-14.0], I2 =80.5%) at twelve months, respectively. All-cause mortality was highest in Africa and Asia/Pacific. Overall, 44.1% ([95% CI 36.1-52.2], I2 =91.7%) of patients recovered their LV function within six months and 58.7% ([95% CI 48.1-68.9], I2 =75.8%) within twelve months, respectively. Europe and North America reported the highest prevalence of LV recovery. Frequent prescription of beta-blocker, ACE-I/ARB and bromocriptine/cabergoline were associated with significantly lower all-cause mortality and better LV recovery. CONCLUSION We identified significant global differences in six- and twelve-month outcomes in women with PPCM. Frequent prescription of guideline-directed heart failure therapy was associated with better LV recovery and lower all-cause mortality. Timely initiation and up-titration of heart failure therapy should therefore be strongly encouraged to improve outcome in PPCM. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Julian Hoevelmann
- Cape Heart Institute, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.,Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University Hospital, Homburg (Saar), Deutschland
| | - Mark E Engel
- Division of Cardiology, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Elani Muller
- Cape Heart Institute, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Ameer Hohlfeld
- South African Medical Research Council, Cape Town, South Africa
| | - Michael Böhm
- Cape Heart Institute, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.,Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University Hospital, Homburg (Saar), Deutschland
| | - Karen Sliwa
- Cape Heart Institute, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.,Department of Medicine, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Charle Viljoen
- Cape Heart Institute, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.,Department of Medicine, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Sanusi M, Momin ES, Mannan V, Kashyap T, Pervaiz MA, Akram A, Khan AA, Elshaikh AO. Using Echocardiography and Biomarkers to Determine Prognosis in Peripartum Cardiomyopathy: A Systematic Review. Cureus 2022; 14:e26130. [PMID: 35875281 PMCID: PMC9299948 DOI: 10.7759/cureus.26130] [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: 03/18/2022] [Accepted: 06/20/2022] [Indexed: 11/05/2022] Open
Abstract
Peripartum cardiomyopathy (PPCM) is a rare but debilitating form of heart failure that affects pregnant women. Although PPCM has a high rate of complete resolution, some patients often have a progressive disease and develop significant morbidity and mortality. Making an accurate prediction of outcomes and identifying those patients at the highest risk has proven difficult over the years. This study aimed to establish if we can use echocardiographic parameters and biomarkers as reliable indicators of prognosis. A predetermined systematic search strategy was employed in four databases: PubMed, Google Scholar, Science Direct, and Cochrane Library to include articles from the last 15 years (January 2007 to January 2022). Data from 12 studies were synthesized and included in this study. Although no parameter proved consistent in all the studies, echocardiographic parameters, including strain profiles and biomarkers, proved significant in the prognostication of patients with PPCM in the various studies evaluated. Therefore, a holistic approach is still needed in the risk stratification of patients with PPCM. Future studies should evaluate these parameters as well as clinical characteristics in a larger cohort study with a long follow-up period of more than one year in order to potentially develop prognostic score criteria that can be used to accurately identify those patients at the highest risk of developing severe disease or death to allow for timely and targeted therapies to improve outcomes in these patients.
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8
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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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9
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Sliwa K, Bauersachs J, Arany Z, Spracklen TF, Hilfiker-Kleiner D. Peripartum cardiomyopathy: from genetics to management. Eur Heart J 2021; 42:3094-3102. [PMID: 34322694 DOI: 10.1093/eurheartj/ehab458] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 06/02/2021] [Accepted: 07/08/2021] [Indexed: 11/14/2022] Open
Abstract
Peripartum cardiomyopathy (PPCM) is a disease that occurs globally in all ethnic groups and should be suspected in any peripartum women presenting with symptoms and signs of heart failure, towards the end of pregnancy or in the months following delivery, with confirmed left ventricular dysfunction. After good history taking, all women should be thoroughly assessed, and alternative causes should be excluded. Urgent cardiac investigations with electrocardiogram and natriuretic peptide measurement (if available) should be performed. Echocardiography follows as the next step in investigation. Patients with abnormal cardiac investigations should be urgently referred to a cardiology team for expert management. Referral for genetic work-up should be considered if there is a family history of cardiomyopathy or sudden death. PPCM is a disease with substantial maternal and neonatal morbidity and mortality. Maternal mortality rates range widely, from 0% to 30%, depending on the ethnic background and geographic region. Just under half of women experience myocardial recovery. Remarkable advances in the comprehension of the pathogenesis and in patient management and therapy have been achieved, largely due to team efforts and close collaboration between basic scientists, cardiologists, intensive care specialists, and obstetricians. This review summarizes current knowledge of PPCM genetics, pathophysiology, diagnostic approach, management, and outcome.
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Affiliation(s)
- Karen Sliwa
- Cape Heart Institute, Faculty of Health Sciences, University of Cape Town, South Africa.,Department of Medicine, Division of Cardiology, Groote Schuur Hospital, University of Cape Town, South Africa
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Zolt Arany
- Cardiovascular Institute, University of Pennsylvania, Philadelphia, PA, USA
| | - Timothy F Spracklen
- Cape Heart Institute, Faculty of Health Sciences, University of Cape Town, South Africa
| | - Denise Hilfiker-Kleiner
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany.,Medical Faculty of the Philipps University Marburg, Marburg, Germany
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10
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Risk Stratification for Subsequent Pregnancy After Prior Peripartum Cardiomyopathy. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2021. [DOI: 10.1007/s11936-020-00882-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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11
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Nabbaale J, Okello E, Kibirige D, Ssekitoleko I, Isanga J, Karungi P, Sebatta E, Zhu ZW, Nakimuli A, Omagino J, Kayima J. Burden, predictors and short-term outcomes of peripartum cardiomyopathy in a black African cohort. PLoS One 2020; 15:e0240837. [PMID: 33085703 PMCID: PMC7577461 DOI: 10.1371/journal.pone.0240837] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 10/02/2020] [Indexed: 11/21/2022] Open
Abstract
Background Peripartum cardiomyopathy (PPCM) is an idiopathic cardiomyopathy presenting with acute heart failure during the peripartum period. It is common in patients of African ancestry. Currently, there is paucity of data on the burden, predictors and outcomes of PPCM in Uganda. This study aimed to investigate the prevalence, predictors and six-month outcomes of PPCM in an adult cohort attending a tertiary specialised cardiology centre in Kampala, Uganda. Methods This study consecutively enrolled 236 women presenting with features of acute heart failure in the peripartum period. Clinical evaluation and echocardiography were performed on all the enrolled women. PCCM was defined according to recommendations of the Heart Failure Association of the European Society of Cardiology Working Group on PPCM. Poor outcome at six months of follow-up was defined as presence of any of the following: death of a mother or her baby, New York Heart Association (NYHA) functional class III-IV or failure to achieve complete recovery of left ventricular function (left ventricular ejection fraction ≤55%). Results The median age, BMI and parity of the study participants was 31.5 (25.5–38.0) years, 28.3 (26.4–29.7) and 3 (2–4) respectively. The prevalence of PPCM was 17.4% (n = 41/236). Multiple pregnancy was the only predictor of PPCM in this study population (OR 4.3 95% CI 1.16–16.05, p = 0.029). Poor outcome at six-months was observed in about 54% of the patients with PPCM (n = 4, 9.8% in NYHA functional class III-IV and n = 22, 53.7% with LVEF <55%). No maternal or foetal mortality was documented. Conclusion PPCM is relatively common in Uganda and is associated with multiple pregnancy. Poor outcomes especially absence of complete recovery of left ventricular function are also common. Large studies to further investigate long-term maternal and foetal outcomes in Uganda are justified.
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Affiliation(s)
- Juliet Nabbaale
- Division of Adult Cardiology, Uganda Heart Institute, Kampala, Uganda
- * E-mail:
| | - Emmy Okello
- Division of Adult Cardiology, Uganda Heart Institute, Kampala, Uganda
| | - Davis Kibirige
- Department of Medicine, Uganda Martyrs Hospital Lubaga, Kampala, Uganda
| | - Isaac Ssekitoleko
- Statistics Unit, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Joseph Isanga
- Department of Obstetrics and Gynaecology, Case Hospital, Kampala, Uganda
| | - Patience Karungi
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - Elias Sebatta
- Division of Adult Cardiology, Uganda Heart Institute, Kampala, Uganda
| | - Zhang Wan Zhu
- Division of Adult Cardiology, Uganda Heart Institute, Kampala, Uganda
| | - Annettee Nakimuli
- Department of Obstetrics and Gynaecology, School of Medicine-Makerere University College of Health Sciences, Kampala, Uganda
| | - John Omagino
- Division of Adult Cardiology, Uganda Heart Institute, Kampala, Uganda
| | - James Kayima
- Division of Adult Cardiology, Uganda Heart Institute, Kampala, Uganda
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Karaye KM, Sa'idu H, Balarabe SA, Ishaq NA, Sanni B, Abubakar H, Mohammed BL, Abdulsalam T, Tukur J, Mohammed IY. Selenium supplementation in patients with peripartum cardiomyopathy: a proof-of-concept trial. BMC Cardiovasc Disord 2020; 20:457. [PMID: 33087055 PMCID: PMC7579991 DOI: 10.1186/s12872-020-01739-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 10/12/2020] [Indexed: 12/29/2022] Open
Abstract
Background We studied the efficacy and safety of selenium supplementation in patients who had peripartum cardiomyopathy (PPCM) and selenium deficiency. Methods We randomly assigned 100 PPCM patients with left ventricular ejection fraction (LVEF) < 45% and selenium deficiency (< 70 μg/L) to receive either oral Selenium (L-selenomethionine) 200 μg/day for 3 months or nothing, in addition to recommended therapy, in an open-label randomised trial. The primary outcome was a composite of persistence of heart failure (HF) symptoms, unrecovered LV systolic function (LVEF < 55%) or death from any cause. Results Over a median of 19 months, the primary outcome occurred in 36 of 46 patients (78.3%) in the selenium group and in 43 of 54 patients (79.6%) in the control group (hazard ratio [HR] 0.69; 95% confidence interval [CI] 0.43–1.09; p = 0.113). Persistence of HF symptoms occurred in 18 patients (39.1%) in the selenium group and in 37 patients (68.5%) in the control group (HR 0.53; 95% CI 0.30–0.93; p = 0.006). LVEF < 55% occurred in 33 patients (71.7%) in the selenium group and in 38 patients (70.4%) in the control group (HR 0.91; 95% CI 0.57–1.45; p = 0.944). Death from any cause occurred in 3 patients (6.5%) in the selenium group and in 9 patients (16.7%) in the control group (HR 0.37; 95% CI 0.10–1.37; p = 0.137). Conclusions In this study, selenium supplementation did not reduce the risk of the primary outcome, but it significantly reduced HF symptoms, and there was a trend towards a reduction of all-cause mortality. Clinical trial registration ClinicalTrials.gov Identifier: NCT03081949.
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Affiliation(s)
- Kamilu M Karaye
- Department of Medicine, Bayero University, PO Box 4445, Kano, Nigeria. .,Department of Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria. .,Department of Public Health and Clinical Medicine, Umea University, Umeå, Sweden.
| | - Hadiza Sa'idu
- Department of Medicine, Bayero University, PO Box 4445, Kano, Nigeria.,Department of Medicine, Murtala Mohammed Specialist Hospital, Kano, Nigeria
| | - Suleiman A Balarabe
- Department of Medicine, Muhammad Abdullahi Wase Specialist Hospital, Kano, Nigeria
| | - Naser A Ishaq
- Department of Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Bushra Sanni
- Department of Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Haruna Abubakar
- Department of Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria
| | | | | | - Jamilu Tukur
- Department of Obstetrics and Gynaecology, Bayero University and Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Idris Y Mohammed
- Department of Chemical Pathology, Bayero University and Aminu Kano Teaching Hospital, Kano, Nigeria
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Azibani F, Pfeffer TJ, Ricke-Hoch M, Dowling W, Pietzsch S, Briton O, Baard J, Abou Moulig V, König T, Berliner D, Libhaber E, Schlothauer S, Anthony J, Lichtinghagen R, Bauersachs J, Sliwa K, Hilfiker-Kleiner D. Outcome in German and South African peripartum cardiomyopathy cohorts associates with medical therapy and fibrosis markers. ESC Heart Fail 2020; 7:512-522. [PMID: 32064780 PMCID: PMC7160487 DOI: 10.1002/ehf2.12553] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 10/01/2019] [Accepted: 10/17/2019] [Indexed: 01/21/2023] Open
Abstract
AIMS This study aims to compare the clinical course of peripartum cardiomyopathy (PPCM) cohorts from Germany (G-PPCM) and South Africa (SA-PPCM) with fibrosis-related markers to get insights into novel pathomechanisms of PPCM. METHODS AND RESULTS G-PPCM (n = 79) and SA-PPCM (n = 72) patients and healthy pregnancy-matched women from Germany (n = 56) and South Africa (n = 40) were enrolled. Circulating levels of procollagen type-I (PINP) and type-III (PIIINP) N-terminal propeptides, soluble ST2, galectin-3, and full-length and cleaved osteopontin (OPN) were measured at diagnosis (baseline) and 6 months of follow-up. Both cohorts received standard heart failure therapy while anticoagulation therapy was applied in 100% of G-PPCM but only in 7% of SA-PPCM patients. In G-PPCM patients, baseline left ventricular ejection fraction (LVEF) was lower, and outcome was better (baseline LVEF, 24 ± 8%, full recovery: 52%, mortality: 0%) compared with SA-PPCM patients (baseline LVEF: 30 ± 9%, full recovery: 32%, mortality: 11%; P < 0.05). At baseline, PINP/PIIINP ratio was lower in SA-PPCM and higher in G-PPCM compared with respective controls, whereas total OPN was elevated in both collectives. Cleaved OPN, which increases PIIINP levels, is generated by thrombin and was reduced in patients receiving anticoagulation therapy. High baseline galectin-3, soluble ST2, and OPN levels were associated with poor outcome in all PPCM patients. CONCLUSIONS SA-PPCM patients displayed a more profibrotic biomarker profile, which was associated with a less favourable outcome despite better cardiac function at baseline, compared with G-PPCM patients. Use of bromocriptine and anticoagulation therapy in G-PPCM may counteract fibrosis and may in part be responsible for their better outcome.
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Affiliation(s)
- Feriel Azibani
- Hatter Institute for Cardiovascular Research in Africa, Department of Medicine, Faculty of Health Sciences, Groote Schuur Hospital, University of Cape Town, 1 Anzio Road, Bag X3 7935, bservatory, Cape Town, South Africa
| | - Tobias J Pfeffer
- Department of Cardiology and Angiology, MHH, Hannover Medical School, Carl-Neuberg-Str. 1, D-30625, Hannover, Germany
| | - Melanie Ricke-Hoch
- Department of Cardiology and Angiology, MHH, Hannover Medical School, Carl-Neuberg-Str. 1, D-30625, Hannover, Germany
| | - Wentzel Dowling
- Hatter Institute for Cardiovascular Research in Africa, Department of Medicine, Faculty of Health Sciences, Groote Schuur Hospital, University of Cape Town, 1 Anzio Road, Bag X3 7935, bservatory, Cape Town, South Africa
| | - Stefan Pietzsch
- Department of Cardiology and Angiology, MHH, Hannover Medical School, Carl-Neuberg-Str. 1, D-30625, Hannover, Germany
| | - Olivia Briton
- Hatter Institute for Cardiovascular Research in Africa, Department of Medicine, Faculty of Health Sciences, Groote Schuur Hospital, University of Cape Town, 1 Anzio Road, Bag X3 7935, bservatory, Cape Town, South Africa
| | - Johann Baard
- Hatter Institute for Cardiovascular Research in Africa, Department of Medicine, Faculty of Health Sciences, Groote Schuur Hospital, University of Cape Town, 1 Anzio Road, Bag X3 7935, bservatory, Cape Town, South Africa
| | - Valeska Abou Moulig
- Department of Cardiology and Angiology, MHH, Hannover Medical School, Carl-Neuberg-Str. 1, D-30625, Hannover, Germany
| | - Tobias König
- Department of Cardiology and Angiology, MHH, Hannover Medical School, Carl-Neuberg-Str. 1, D-30625, Hannover, Germany
| | - Dominik Berliner
- Department of Cardiology and Angiology, MHH, Hannover Medical School, Carl-Neuberg-Str. 1, D-30625, Hannover, Germany
| | - Elena Libhaber
- School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Stella Schlothauer
- Department of Cardiology and Angiology, MHH, Hannover Medical School, Carl-Neuberg-Str. 1, D-30625, Hannover, Germany
| | - John Anthony
- Division of Obstetrics and Gynaecology, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Ralf Lichtinghagen
- Department of Clinical Chemistry, Hannover Medical School, Hannover, Germany
| | - Johann Bauersachs
- Department of Cardiology and Angiology, MHH, Hannover Medical School, Carl-Neuberg-Str. 1, D-30625, Hannover, Germany
| | - Karen Sliwa
- Hatter Institute for Cardiovascular Research in Africa, Department of Medicine, Faculty of Health Sciences, Groote Schuur Hospital, University of Cape Town, 1 Anzio Road, Bag X3 7935, bservatory, Cape Town, South Africa
| | - Denise Hilfiker-Kleiner
- Department of Cardiology and Angiology, MHH, Hannover Medical School, Carl-Neuberg-Str. 1, D-30625, Hannover, Germany
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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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15
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Moulig V, Pfeffer TJ, Ricke‐Hoch M, Schlothauer S, Koenig T, Schwab J, Berliner D, Pfister R, Michels G, Haghikia A, Falk CS, Duncker D, Veltmann C, Hilfiker‐Kleiner D, Bauersachs J. Long‐term follow‐up in peripartum cardiomyopathy patients with contemporary treatment: low mortality, high cardiac recovery, but significant cardiovascular co‐morbidities. Eur J Heart Fail 2019; 21:1534-1542. [DOI: 10.1002/ejhf.1624] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 06/22/2019] [Accepted: 09/02/2019] [Indexed: 11/07/2022] Open
Affiliation(s)
- Valeska Moulig
- Department of Cardiology and AngiologyHannover Medical School Hannover Germany
| | | | - Melanie Ricke‐Hoch
- Department of Cardiology and AngiologyHannover Medical School Hannover Germany
| | - Stella Schlothauer
- Department of Cardiology and AngiologyHannover Medical School Hannover Germany
| | - Tobias Koenig
- Department of Cardiology and AngiologyHannover Medical School Hannover Germany
| | - Johannes Schwab
- Department of CardiologyParacelsus Medical University, General Hospital Nuremberg Nuremberg Germany
| | - Dominik Berliner
- Department of Cardiology and AngiologyHannover Medical School Hannover Germany
| | - Roman Pfister
- Department of Cardiology, Pulmonology, and Vascular MedicineUniversity of Cologne, Faculty of Medicine and University Hospital Cologne Cologne Germany
| | - Guido Michels
- Department of Cardiology, Pulmonology, and Vascular MedicineUniversity of Cologne, Faculty of Medicine and University Hospital Cologne Cologne Germany
| | - Arash Haghikia
- Department of Cardiology, Charité UniversitätsmedizinCampus Benjamin Franklin Berlin Germany
| | - Christine S. Falk
- Institute of Transplant ImmunologyHannover Medical School Hannover Germany
| | - David Duncker
- Department of Cardiology and AngiologyHannover Medical School Hannover Germany
| | - Christian Veltmann
- Department of Cardiology and AngiologyHannover Medical School Hannover Germany
| | | | - Johann Bauersachs
- Department of Cardiology and AngiologyHannover Medical School Hannover Germany
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16
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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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17
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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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18
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Westhoff-Bleck M, Hilfiker-Kleiner D, Pankuweit S, Schieffer B. Cardiomyopathies and Congenital Heart Disease in Pregnancy. Geburtshilfe Frauenheilkd 2018; 78:1256-1261. [PMID: 30655649 PMCID: PMC6294643 DOI: 10.1055/a-0774-8696] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 10/26/2018] [Accepted: 10/27/2018] [Indexed: 01/30/2023] Open
Abstract
Pregnancy-associated diseases of the cardiovascular system occur in up to 10% of all pregnancies and the incidence is increasing. Besides congenital heart disease or pre-existing cardiomyopathy in the mother, the clinical focus has moved especially to peripartum cardiomyopathy (PPCM) because of the condition's dramatic clinical course and the identification of the underlying mechanisms. This review article concentrates therefore on PPCM, which occurs either in the last month of pregnancy or in the first 6 months following delivery in women with previously healthy hearts. The global incidence is estimated today at roughly 1 : 1000 pregnancies. The condition is heterogeneous, ranging from mild disease to severe acute heart failure with cardiogenic shock and sudden cardiac death of the mother. Important risk factors are pregnancy-associated hypertensive complications, multiple pregnancy and greater maternal age. The pathogenesis comprises cleavage, induced by increased oxidative stress, of the lactation hormone prolactin into a toxic hormone fragment that damages blood vessels, known as the 16-kDalton protein fragment. The lactation-blocking drug bromocriptine prevents prolactin release and promotes healing of PPCM in combination with pharmacological heart failure therapy; it appears to prevent recurrence in subsequent pregnancies. Uncomplicated pregnancy is possible in most patients with congenital heart disease. The foetal complications include an increased abortion rate, prematurity and smallness for gestational age, as well as an increased risk of cardiac malformations. The maternal risk comprises mainly arrhythmias, progressive heart failure and thrombembolic complications, with the risk of vessel dissection with a low mortality risk of < 1% in the case of aortopathies. Individual risk assessment and corresponding close monitoring of the pregnancy are required.
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Affiliation(s)
- Mechthild Westhoff-Bleck
- Medizinische Hochschule Hannover, Molekulare Kardiologie, Abteilung für Kardiologie und Angiologie, Hannover, Germany
| | - Denise Hilfiker-Kleiner
- Medizinische Hochschule Hannover, Molekulare Kardiologie, Abteilung für Kardiologie und Angiologie, Hannover, Germany
| | - Sabine Pankuweit
- Klinik für Innere Medizin, Kardiologie, Angiologie und internistische Intensivmedizin, Klinikum der Philipps-Universität, Marburg, Germany
| | - Bernhard Schieffer
- Klinik für Innere Medizin, Kardiologie, Angiologie und internistische Intensivmedizin, Klinikum der Philipps-Universität, Marburg, Germany
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19
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Peripartum cardiomyopathy-diagnosis, management, and long term implications. Trends Cardiovasc Med 2018; 29:164-173. [PMID: 30111492 DOI: 10.1016/j.tcm.2018.07.012] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 07/02/2018] [Accepted: 07/20/2018] [Indexed: 01/26/2023]
Abstract
Peripartum cardiomyopathy (PPCM) is a potentially life-threatening pregnancy-associated disease that typically arises in the peripartum period. While the disease is relatively uncommon, its incidence is rising. It is a form of idiopathic dilated cardiomyopathy, defined as pregnancy-related left ventricular dysfunction, diagnosed either towards the end of pregnancy or in the months following delivery, in women without any other identifiable cause. The clinical presentation, diagnostic assessment and treatment usually mirror that of other forms of cardiomyopathy. Timing of delivery and management require a multidisciplinary approach and individualization. Subsequent pregnancies generally carry risk, but individualization is required depending on the pre-pregnancy left ventricular function. Recovery occurs in most women on standard medical therapy for heart failure with reduced ejection fraction, more frequently than in other forms of nonischemic cardiomyopathy. The purpose of this review is to summarize the current state of knowledge with regard to diagnosis, treatment and management, with a focus on long term implications.
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20
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Sustained Cardiac Recovery Hinges on Timing and Natural History of Underlying Condition. Am J Med Sci 2018; 356:47-55. [DOI: 10.1016/j.amjms.2018.02.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 11/14/2017] [Accepted: 02/21/2018] [Indexed: 01/12/2023]
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21
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Hilfiker-Kleiner D, Haghikia A, Berliner D, Vogel-Claussen J, Schwab J, Franke A, Schwarzkopf M, Ehlermann P, Pfister R, Michels G, Westenfeld R, Stangl V, Kindermann I, Kühl U, Angermann CE, Schlitt A, Fischer D, Podewski E, Böhm M, Sliwa K, Bauersachs J. Bromocriptine for the treatment of peripartum cardiomyopathy: a multicentre randomized study. Eur Heart J 2018; 38:2671-2679. [PMID: 28934837 PMCID: PMC5837241 DOI: 10.1093/eurheartj/ehx355] [Citation(s) in RCA: 197] [Impact Index Per Article: 32.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 06/23/2017] [Indexed: 12/28/2022] Open
Abstract
Aims An anti-angiogenic cleaved prolactin fragment is considered causal for peripartum cardiomyopathy (PPCM). Experimental and first clinical observations suggested beneficial effects of the prolactin release inhibitor bromocriptine in PPCM. Methods and results In this multicentre trial, 63 PPCM patients with left ventricular ejection fraction (LVEF) ≤35% were randomly assigned to short-term (1W: bromocriptine, 2.5 mg, 7 days) or long-term bromocriptine treatment (8W: 5 mg for 2 weeks followed by 2.5 mg for 6 weeks) in addition to standard heart failure therapy. Primary end point was LVEF change (delta) from baseline to 6 months assessed by magnetic resonance imaging. Bromocriptine was well tolerated. Left ventricular ejection fraction increased from 28 ± 10% to 49 ± 12% with a delta-LVEF of + 21 ± 11% in the 1W-group, and from 27 ± 10% to 51 ± 10% with a delta-LVEF of + 24 ± 11% in the 8W-group (delta-LVEF: P = 0.381). Full-recovery (LVEF ≥ 50%) was present in 52% of the 1W- and in 68% of the 8W-group with no differences in secondary end points between both groups (hospitalizations for heart failure: 1W: 9.7% vs. 8W: 6.5%, P = 0.651). The risk within the 8W-group to fail full-recovery after 6 months tended to be lower. No patient in the study needed heart transplantation, LV assist device or died. Conclusion Bromocriptine treatment was associated with high rate of full LV-recovery and low morbidity and mortality in PPCM patients compared with other PPCM cohorts not treated with bromocriptine. No significant differences were observed between 1W and 8W treatment suggesting that 1-week addition of bromocriptine to standard heart failure treatment is already beneficial with a trend for better full-recovery in the 8W group. Clinical trial registration ClinicalTrials.gov, study number: NCT00998556.
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Affiliation(s)
- Denise Hilfiker-Kleiner
- Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1. D-30625 Hannover, Germany
| | - Arash Haghikia
- Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1. D-30625 Hannover, Germany.,Department of Cardiology, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Dominik Berliner
- Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1. D-30625 Hannover, Germany
| | - Jens Vogel-Claussen
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Johannes Schwab
- Universitätsklinik für Innere Medizin 8 - Schwerpunkt Kardiologie und Institut für Radiologie und Neuroradiologie, Klinikum Nürnberg Süd, Paracelsus, Medizinische Privatuniversität Nürnberg, Breslauer Str. 201, 90471 Nürnberg, Germany
| | - Annegret Franke
- Faculty of Medicine, University Leipzig, Clinical Trial Centre (KKS), ZKS Leipzig, Haertelstr. 16-18, D-04103 Leipzig, Germany
| | - Marziel Schwarzkopf
- Faculty of Medicine, University Leipzig, Clinical Trial Centre (KKS), ZKS Leipzig, Haertelstr. 16-18, D-04103 Leipzig, Germany
| | - Philipp Ehlermann
- Department of Cardiology, Angiology, and Pneumology, University of Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany
| | - Roman Pfister
- Department of Cardiology, Pulmonology, and Vascular Medicine, University of Cologne, Cologne, Kerpenerstr. 62, 50937 Köln, Germany
| | - Guido Michels
- Department of Cardiology, Pulmonology, and Vascular Medicine, University of Cologne, Cologne, Kerpenerstr. 62, 50937 Köln, Germany
| | - Ralf Westenfeld
- Department of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty, University Duesseldorf, Duesseldorf, Germany
| | - Verena Stangl
- Department for Cardiology and Angiology, Angiologie, Center for Cardiovascular Research (CCR), Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Ingrid Kindermann
- Department of Internal Medicine III, University Hospital of the Saarland, 66421 Homburg/Saar, Germany
| | - Uwe Kühl
- Department of Cardiology, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Christiane E Angermann
- Department of Internal Medicine I, University Hospital Wuerzburg, Am Schwarzenberg 15, Haus A1597078 Würzburg, Germany
| | - Axel Schlitt
- Department of Medicine III, Medizinische Fakultät der Martin Luther-Universität Halle-Wittenberg, Magdeburger Straße 8, 06108 Halle, Germany
| | - Dieter Fischer
- Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1. D-30625 Hannover, Germany
| | - Edith Podewski
- Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1. D-30625 Hannover, Germany
| | - Michael Böhm
- Department of Internal Medicine III, University Hospital of the Saarland, 66421 Homburg/Saar, Germany
| | - Karen Sliwa
- Faculty of Health Sciences, Hatter Institute of Cardiology Research in Africa, 2 Anzio Road, Chris Barnard Building, 4th Floor, OBSERVATORY 7925, South Africa
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1. D-30625 Hannover, Germany
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22
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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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23
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Sliwa K, Petrie MC, Hilfiker-Kleiner D, Mebazaa A, Jackson A, Johnson MR, van der Meer P, Mbakwem A, Bauersachs J. Long-term prognosis, subsequent pregnancy, contraception and overall management of peripartum cardiomyopathy: practical guidance paper from the Heart Failure Association of the European Society of Cardiology Study Group on Peripartum Cardiomyopathy. Eur J Heart Fail 2018; 20:951-962. [PMID: 29578284 DOI: 10.1002/ejhf.1178] [Citation(s) in RCA: 84] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 02/11/2018] [Accepted: 02/20/2018] [Indexed: 12/28/2022] Open
Abstract
Peripartum cardiomyopathy is an idiopathic cardiomyopathy presenting with heart failure secondary to left ventricular systolic dysfunction towards the end of pregnancy or in the months following delivery, where no other cause for heart failure is identified. Outcome varies from full recovery to residual left ventricular systolic dysfunction and even death. Many women return to their physician to acquire information on their long-term prognosis, to seek medical advice regarding contraception, or when planning a subsequent pregnancy. This position paper summarizes current evidence for long-term outcome, risk stratification of further pregnancies and overall management. Based on the best available evidence, as well as the clinical experience of the European Society of Cardiology Study Group on Peripartum Cardiomyopathy members, a consensus on pre- and postpartum management algorithms for women undergoing a subsequent pregnancy is presented.
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Affiliation(s)
- Karen Sliwa
- Hatter Institute for Cardiovascular Research in Africa, Department of Medicine & Cardiology, Faculty of Health Sciences, University of Cape Town, South Africa.,Mary McKillop Institute, ACU, Melbourne, Australia
| | | | | | - Alexandre Mebazaa
- Hôpital Lariboisière, Université Paris Diderot, Inserm U942, Paris, France
| | | | - Mark R Johnson
- Department of Obstetrics, Imperial College School of Medicine, Chelsea and Westminster Hospital, London, UK
| | - Peter van der Meer
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Amam Mbakwem
- Department of Cardiology, Lagos University Hospital, Lagos
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Medizinische Hochschule Hannover, Hannover, Germany
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24
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Koenig T, Bauersachs J, Hilfiker-Kleiner D. Bromocriptine for the Treatment of Peripartum Cardiomyopathy. Card Fail Rev 2018; 4:46-49. [PMID: 29892477 DOI: 10.15420/cfr.2018:2:2] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Peripartum cardiomyopathy (PPCM) is a life-threatening, pregnancy-associated heart disease that develops towards the end of pregnancy or in the first months following delivery in previously healthy women. Understanding of the pathophysiology has progressed in recent years, highlighting an oxidative-stress mediated cleavage of the nursing hormone prolactin into a toxic 16-kDa prolactin fragment as a major factor driving the disease. The 16-kDa prolactin fragment induces detrimental but potentially reversible effects on heart function. Bromocriptine, a clinically-approved drug to block prolactin release, was initially tested in a PPCM mouse model where it efficiently prevented the onset of PPCM. Consequently, this treatment concept was transferred to and successfully used in humans as a bench-tobedside approach. Encouraging proof-of-concept studies led to a randomised trial that further strengthens the role of bromocriptine in addition to standard heart failure therapy in clinical practice. The aim of this article is to summarise this novel and disease-specific medical treatment, along with current knowledge on the epidemiology and pathophysiology of PPCM.
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Affiliation(s)
- Tobias Koenig
- Department of Cardiology and Angiology, Hannover Medical School Hannover, Germany
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School Hannover, Germany
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Yamanoglu A, Celebi Yamanoglu NG, Cakmak S, Sogut O. A young puerperal woman presenting to emergency department with severe dyspnea. Turk J Emerg Med 2017; 17:154-156. [PMID: 29464221 PMCID: PMC5812892 DOI: 10.1016/j.tjem.2017.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Accepted: 07/03/2017] [Indexed: 01/12/2023] Open
Abstract
Peripartum cardiomyopathy (PPCM) is an idiopathic cardiomyopathy presenting with heart failure (HF) secondary to left ventricular systolic dysfunction towards the end of pregnancy or in the months following delivery, where no other cause of HF is found. The symptoms and signs of this rare disorder mimic those of the physiological changes of pregnancy or other cardiovascular diseases. Consequently, its diagnosis is frequently delayed, which worsens an already poor prognosis. Here, we report a young adult who was diagnosed with PPCM, early, with the help of focused cardiac ultrasonography, performed after presenting to the emergency department with nonspecific respiratory complaints, including dyspnea and hemoptysis, which suggested at first pulmonary embolism.
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Affiliation(s)
- Adnan Yamanoglu
- Haseki Education and Research Hospital, Department of Emergency Medicine, Istanbul, Turkey
| | | | - Sumeyye Cakmak
- Haseki Education and Research Hospital, Department of Emergency Medicine, Istanbul, Turkey
| | - Ozgur Sogut
- Haseki Education and Research Hospital, Department of Emergency Medicine, Istanbul, Turkey
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Elkayam U. Peripartum cardiomyopathy for the clinician: the known and the unknown. Eur J Heart Fail 2017; 19:1142-1144. [DOI: 10.1002/ejhf.840] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 03/14/2017] [Indexed: 01/06/2023] Open
Affiliation(s)
- Uri Elkayam
- Department of Medicine, Division of Cardiovascular Disease, and Department of Obstetrics and Gynaecology, Keck School of Medicine; University of Southern California; Los Angeles CA USA
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Ersbøll AS, Johansen M, Damm P, Rasmussen S, Vejlstrup NG, Gustafsson F. Peripartum cardiomyopathy in Denmark: a retrospective, population-based study of incidence, management and outcome. Eur J Heart Fail 2017; 19:1712-1720. [PMID: 28597481 DOI: 10.1002/ejhf.882] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 03/24/2017] [Accepted: 04/10/2017] [Indexed: 12/28/2022] Open
Abstract
AIM Population-based European studies of peripartum cardiomyopathy (PPCM) are few. We aimed to estimate the nationwide incidence and outcome of PPCM in Denmark during 2005-2014. METHODS AND RESULTS The Danish National Birth Register and the Danish National Patient Register were linked and searched for cardiomyopathy and heart failure ICD-10 diagnoses in a period of nine months before to 12 months after a delivery from 1 January 2005 through 31 December 2014. Diagnoses were validated and additional data were extracted from patient charts. A total of 61 women met the inclusion criteria equalling 1 in 10 149 deliveries. The majority recovered left ventricular systolic function within one year, but 14.8% suffered a major adverse event with 3.3% mortality, 8.2% mechanical circulatory support requirement and/or heart transplantation and 4.9% persistent severe heart failure. Half of the women had a concomitant hypertensive disorder of pregnancy, and this subgroup had a milder course of the disease. Baseline left ventricular ejection fraction (LVEF) was the only significant predictor of LVEF 10-14 months after diagnosis, and cabergoline therapy to inhibit lactation predicted the dichotomous outcome of complete recovery (LVEF ≥55%). CONCLUSION The first validated, population-based European estimate of PPCM incidence is 1 in 10 149 deliveries, which places Denmark between American and Japanese estimates. Clinical outcome in the cohort was similar to those reported in recent cohorts. Women with concomitant hypertensive disorder of pregnancy had a milder course of PPCM. Baseline LVEF predicted LVEF 10-14 months after diagnosis and cabergoline predicted complete recovery.
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Affiliation(s)
- Anne S Ersbøll
- Department of Obstetrics, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Marianne Johansen
- Department of Obstetrics, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Peter Damm
- Department of Obstetrics, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Science, University of Copenhagen, Copenhagen, Denmark
| | | | - Niels G Vejlstrup
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Finn Gustafsson
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
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Barasa A, Goloskokova V, Ladfors L, Patel H, Schaufelberger M. Symptomatic recovery and pharmacological management in a clinical cohort with peripartum cardiomyopathy. J Matern Fetal Neonatal Med 2017; 31:1342-1349. [DOI: 10.1080/14767058.2017.1317341] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- Anders Barasa
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Medicine, Aga Khan University Hospital, Nairobi, Kenya
| | - Valentina Goloskokova
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lars Ladfors
- Department of Obstetrics and Gynaecology, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
| | - Harshida Patel
- Faculty of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Maria Schaufelberger
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Gambahaya ET, Hakim J, Kao D, Munyandu N, Matenga J. Peripartum cardiomyopathy among cardiovascular patients referred for echocardiography at Parirenyatwa Teaching Hospital, Harare, Zimbabwe. Cardiovasc J Afr 2017; 28:8-13. [PMID: 28262909 PMCID: PMC5423423 DOI: 10.5830/cvja-2016-043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 04/03/2016] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVES The main aim was to evaluate the outcome of patients with peripartum cardiomyopathy (PPCM) within six months of diagnosis. The secondary aim was to describe demographic and clinical characteristics of patients with PPCM in Harare, Zimbabwe. METHODS This was a prospective cohort study in which patients recruited into a detailed PPCM registry were followed up for six months. Echocardiograms were performed at enrolment, and three and six months after diagnosis, to determine left ventricular function. RESULTS From 1 August 2012 to 31 July 2013, 43 patients with a new diagnosis of PPCM were recruited at Parirenyatwa Hospital in Harare. At six months, mean ejection fraction improved from 29.7 ± 9.8 to 44.9 ± 14.9%, p < 0.001 and New York Heart Association (NYHA) functional class improved significantly (p < 0.0001). Five (11.6%) patients died. CONCLUSIONS Left ventricular function improved in a substantial number of patients (42.9%) in this Zimbabwean cohort compared to other African cohorts. However the mortality rate remained high.
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Affiliation(s)
| | - James Hakim
- College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - David Kao
- Division of Cardiology, Department of Medicine, University of Colorado Denver School of Medicine, Colorado, USA
| | - Noleen Munyandu
- College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Jonathan Matenga
- College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
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Ersbøll AS, Damm P, Gustafsson F, Vejlstrup NG, Johansen M. Peripartum cardiomyopathy: a systematic literature review. Acta Obstet Gynecol Scand 2017; 95:1205-1219. [PMID: 27545093 DOI: 10.1111/aogs.13005] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 08/16/2016] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Peripartum cardiomyopathy (PPCM) is a rare but potentially fatal disease defined by heart failure towards the end of pregnancy or in the months following delivery. We aim to raise awareness of the condition and give the clinician an overview of current knowledge on the mechanisms of pathophysiology, diagnostics and clinical management. MATERIAL AND METHODS Systematic literature searches were performed in PubMed and Embase up to June 2016. Cohorts of more than 20 women with PPCM conducted after 2000 were selected to report contemporary outcomes and prognostic data. Guidelines and reviews that provided comprehensive overviews were included, too. RESULTS New research on the pathophysiological mechanisms of PPCM points towards a two-hit multifactorial cause involving genetic factors and an antiangiogenic hormonal environment of late gestation with high levels of prolactin and sFlt-1. The prevalence of concomitant preeclampsia is high (often 30-45%) and symptoms can be similar, posing diagnostic difficulties. Most women (71-98%) present postpartum. Echocardiography is essential for diagnosis, and cardiac magnetic resonance imaging may provide new insights to pathophysiology and prognosis. Management is multidisciplinary and involves advanced heart failure therapy. Treatment, timing and mode of delivery in pregnant women depend on disease severity. The risk of relapse in subsequent pregnancies is >20%, and women are often advised against a new pregnancy. CONCLUSIONS PPCM has a huge impact on cardiovascular health and reproductive life perspective. New insights into genetics, molecular pathophysiological mechanisms and clinical studies have resulted in potential disease-specific therapies, but many questions remain unanswered.
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Affiliation(s)
- Anne S Ersbøll
- Center for Pregnancy and Heart Disease, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark. .,Department of Obstetrics, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark.
| | - Peter Damm
- Department of Obstetrics, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark.,Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Niels G Vejlstrup
- Center for Pregnancy and Heart Disease, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark.,Department of Cardiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Marianne Johansen
- Center for Pregnancy and Heart Disease, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark.,Department of Obstetrics, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
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Peripartum Cardiomyopathy: Do Exosomes Play a Role? ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2017; 998:139-149. [PMID: 28936737 DOI: 10.1007/978-981-10-4397-0_9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Peripartum cardiomyopathy (PPCM) refers to irreversible cardiomyocyte damage that occurs during the last month of pregnancy, or within 5 months after giving birth. It is characterized by systolic heart failure. This life-threatening condition is relatively uncommon, but the incidence has been climbing up. Because of its high mortality, it is crucial for physicians to have high suspicious for the disease. Studies have been done to search into specific lab test and treatment for PPCM. Therapies like anti-viral, anti-inflammatory and immunosuppression regimen have been explored. New regimen like exosomes has also been explored and revealed promising effects.
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Ntusi NBA, Badri M, Gumedze F, Sliwa K, Mayosi BM. Pregnancy-Associated Heart Failure: A Comparison of Clinical Presentation and Outcome between Hypertensive Heart Failure of Pregnancy and Idiopathic Peripartum Cardiomyopathy. PLoS One 2015; 10:e0133466. [PMID: 26252951 PMCID: PMC4529210 DOI: 10.1371/journal.pone.0133466] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Accepted: 06/28/2015] [Indexed: 01/26/2023] Open
Abstract
Aims There is controversy regarding the inclusion of patients with hypertension among cases of peripartum cardiomyopathy (PPCM), as the practice has contributed significantly to the discrepancy in reported characteristics of PPCM. We sought to determine whether hypertensive heart failure of pregnancy (HHFP) (i.e., peripartum cardiac failure associated with any form of hypertension) and PPCM have similar or different clinical features and outcome. Methods and Results We compared the time of onset of symptoms, clinical profile (including electrocardiographic [ECG] and echocardiographic features) and outcome of patients with HHFP (n = 53; age 29.6 ± 6.6 years) and PPCM (n = 30; age 31.5 ± 7.5 years). The onset of symptoms was postpartum in all PPCM patients, whereas it was antepartum in 85% of HHFP cases (p<0.001). PPCM was more significantly associated with the following features than HHFP (p<0.05): twin pregnancy, smoking, cardiomegaly with lower left ventricular ejection fraction on echocardiography, and longer QRS duration, QRS abnormalities, left atrial hypertrophy, left bundle branch block, T wave inversion and atrial fibrillation on ECG. By contrast, HHFP patients were significantly more likely (p<0.05) to have a family history of hypertension, hypertension and pre-eclampsia in a previous pregnancy, tachycardia at presentation on ECG, and left ventricular hypertrophy on echocardiography. Chronic heart failure, intra-cardiac thrombus and pulmonary hypertension were found significantly more commonly in PPCM than in HHFP (p<0.05). There were 5 deaths in the PPCM group compared to none among HHFP cases (p = 0.005) during follow-up. Conclusion There are significant differences in the time of onset of heart failure, clinical, ECG and echocardiographic features, and outcome of HHFP compared to PPCM, indicating that the presence of hypertension in pregnancy-associated heart failure may not fit the case definition of idiopathic PPCM.
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Affiliation(s)
- Ntobeko B. A. Ntusi
- The Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Motasim Badri
- The Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Freedom Gumedze
- Department of Statistical Sciences, University of Cape Town, Cape Town, South Africa
| | - Karen Sliwa
- Hatter Institute for Cardiovascular Research in Africa, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Bongani M. Mayosi
- The Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
- Hatter Institute for Cardiovascular Research in Africa, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
- * E-mail:
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Withdrawal of heart failure medications in peripartum cardiomyopathy after myocardial recovery. Int J Cardiol 2015; 190:212-3. [PMID: 25920029 DOI: 10.1016/j.ijcard.2015.04.169] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Accepted: 04/20/2015] [Indexed: 11/24/2022]
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Serum selenium and ceruloplasmin in nigerians with peripartum cardiomyopathy. Int J Mol Sci 2015; 16:7644-54. [PMID: 25853263 PMCID: PMC4425040 DOI: 10.3390/ijms16047644] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2015] [Revised: 03/07/2015] [Accepted: 03/31/2015] [Indexed: 11/17/2022] Open
Abstract
The study aimed to determine if selenium deficiency, serum ceruloplasmin and traditional birth practices are risk factors for peripartum cardiomyopathy (PPCM), in Kano, Nigeria. This is a case-control study carried out in three hospitals, and PPCM patients were followed up for six months. Critically low serum selenium concentration was defined as <70 µg/L. A total of 39 PPCM patients and 50 controls were consecutively recruited after satisfying the inclusion criteria. Mean serum selenium in patients (61.7 ± 14.9 µg/L) was significantly lower than in controls (118.4 ± 45.6 µg/L) (p < 0.001). The prevalence of serum selenium <70 µg/L was significantly higher among patients (76.9%) than controls (22.0%) (p < 0.001). The mean ceruloplasmin and prevalence of socio-economic indices, multiparity, pregnancy-induced hypertension, obesity and twin pregnancy were not different between the groups (p > 0.05). Logistic regression showed that rural residency significantly increased the odds for serum selenium <70 µg/L by 2.773-fold (p = 0.037). Baseline serum levels of selenium and ceruloplasmin were not associated with six-month mortality. This study has shown that selenium deficiency is a risk factor for PPCM in Kano, Nigeria, and is related to rural residency. However, serum ceruloplasmin, customary birth practices and some other characteristics were not associated with PPCM in the study area.
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Hilfiker-Kleiner D, Haghikia A, Nonhoff J, Bauersachs J. Peripartum cardiomyopathy: current management and future perspectives. Eur Heart J 2015; 36:1090-7. [PMID: 25636745 PMCID: PMC4422973 DOI: 10.1093/eurheartj/ehv009] [Citation(s) in RCA: 153] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 01/08/2015] [Indexed: 01/06/2023] Open
Abstract
Pregnancy is associated with marked physiological changes challenging the cardiovascular system. Among the more severe pregnancy associated cardiovascular complications, peripartum cardiomyopathy (PPCM) is a potentially life-threatening heart disease emerging towards the end of pregnancy or in the first postpartal months in previously healthy women. A major challenge is to distinguish the peripartum discomforts in healthy women (fatigue, shortness of breath, and oedema) from the pathological symptoms of PPCM. Moreover, pregnancy-related pathologies such as preeclampsia, myocarditis, or underlying genetic disease show overlapping symptoms with PPCM. Difficulties in diagnosis and the discrimination from other pathological conditions in pregnancy may explain why PPCM is still underestimated. Additionally, underlying pathophysiologies are poorly understood, biomarkers are scarce and treatment options in general limited. Experience in long-term prognosis and management including subsequent pregnancies is just beginning to emerge. This review focuses on novel aspects of physiological and pathophysiological changes of the maternal cardiovascular system by comparing normal conditions, hypertensive complications, genetic aspects, and infectious disease in PPCM-pregnancies. It also presents clinical and basic science data on the current state of knowledge on PPCM and brings them in context thereby highlighting promising new insights in diagnostic tools and therapeutic approaches and management.
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Affiliation(s)
- Denise Hilfiker-Kleiner
- Department of Cardiology and Angiology, Medical School Hannover, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Arash Haghikia
- Department of Cardiology and Angiology, Medical School Hannover, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Justus Nonhoff
- Department of Cardiology and Angiology, Medical School Hannover, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Medical School Hannover, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
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Dillon DG, Gurdasani D, Riha J, Ekoru K, Asiki G, Mayanja BN, Levitt NS, Crowther NJ, Nyirenda M, Njelekela M, Ramaiya K, Nyan O, Adewole OO, Anastos K, Azzoni L, Boom WH, Compostella C, Dave JA, Dawood H, Erikstrup C, Fourie CM, Friis H, Kruger A, Idoko JA, Longenecker CT, Mbondi S, Mukaya JE, Mutimura E, Ndhlovu CE, Praygod G, Pefura Yone EW, Pujades-Rodriguez M, Range N, Sani MU, Schutte AE, Sliwa K, Tien PC, Vorster EH, Walsh C, Zinyama R, Mashili F, Sobngwi E, Adebamowo C, Kamali A, Seeley J, Young EH, Smeeth L, Motala AA, Kaleebu P, Sandhu MS. Association of HIV and ART with cardiometabolic traits in sub-Saharan Africa: a systematic review and meta-analysis. Int J Epidemiol 2014; 42:1754-71. [PMID: 24415610 PMCID: PMC3887568 DOI: 10.1093/ije/dyt198] [Citation(s) in RCA: 143] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background Sub-Saharan Africa (SSA) has the highest burden of HIV in the world and a rising prevalence of cardiometabolic disease; however, the interrelationship between HIV, antiretroviral therapy (ART) and cardiometabolic traits is not well described in SSA populations. Methods We conducted a systematic review and meta-analysis through MEDLINE and EMBASE (up to January 2012), as well as direct author contact. Eligible studies provided summary or individual-level data on one or more of the following traits in HIV+ and HIV-, or ART+ and ART- subgroups in SSA: body mass index (BMI), systolic blood pressure (SBP), diastolic blood pressure (DBP), high-density lipoprotein (HDL), low-density lipoprotein (LDL), triglycerides (TGs) and fasting blood glucose (FBG) or glycated hemoglobin (HbA1c). Information was synthesized under a random-effects model and the primary outcomes were the standardized mean differences (SMD) of the specified traits between subgroups of participants. Results Data were obtained from 49 published and 3 unpublished studies which reported on 29 755 individuals. HIV infection was associated with higher TGs [SMD, 0.26; 95% confidence interval (CI), 0.08 to 0.44] and lower HDL (SMD, −0.59; 95% CI, −0.86 to −0.31), BMI (SMD, −0.32; 95% CI, −0.45 to −0.18), SBP (SMD, −0.40; 95% CI, −0.55 to −0.25) and DBP (SMD, −0.34; 95% CI, −0.51 to −0.17). Among HIV+ individuals, ART use was associated with higher LDL (SMD, 0.43; 95% CI, 0.14 to 0.72) and HDL (SMD, 0.39; 95% CI, 0.11 to 0.66), and lower HbA1c (SMD, −0.34; 95% CI, −0.62 to −0.06). Fully adjusted estimates from analyses of individual participant data were consistent with meta-analysis of summary estimates for most traits. Conclusions Broadly consistent with results from populations of European descent, these results suggest differences in cardiometabolic traits between HIV-infected and uninfected individuals in SSA, which might be modified by ART use. In a region with the highest burden of HIV, it will be important to clarify these findings to reliably assess the need for monitoring and managing cardiometabolic risk in HIV-infected populations in SSA.
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Affiliation(s)
- David G Dillon
- Department of Public Health and Primary Care, Institute of Public Health, University of Cambridge, Cambridge, UK, Genetic Epidemiology Group, Wellcome Trust Sanger Institute, Hinxton, Cambridge, UK, MRC/UVRI Uganda Research Unit on AIDS, Entebbe, Uganda, Division of Diabetic Medicine and Endocrinology, Department of Medicine, University of Cape Town, Cape Town, South Africa; Chronic Diseases Initiative in Africa, Department of Chemical Pathology, National Health Laboratory Service, University of the Witwatersrand Medical School, Johannesburg, South Africa, Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi, Department of Physiology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania, Department of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania, Royal Victoria Teaching Hospital, School of Medicine, University of The Gambia, Banjul, The Gambia, Department of Medicine, Obafemi Awolowo University, Ile Ife, Nigeria, Women's Equity in Access to Care &Treatment, Kigali, Rwanda, HIV-1 Immunopathogenesis Laboratory, Wistar Institute, Philadelphia, PA, Tuberculosis Research Unit, Department of Medicine, Case Western Reserve University, Cleveland, OH, Department of Medical and Surgical Sciences, University of Padua, Padua, Italy, Division of Diabetic Medicine and Endocrinology, Department of Medicine, University of Cape Town, Cape Town, South Africa, Infectious Diseases Unit, Department of Medicine, Grey's Hospital, Pietermaritzburg, South Africa, Department of Clinical Immunology, Aarhus University Hospital, Aarhus, Denmark, HART (Hypertension in Africa Research Team), North-West University, Potchefstroom, South Africa, Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Copenhagen, Denmark, Africa Unit for Transdisciplinary Health Research (AUTHeR), North-West University, Potchefstroom, South Africa, Department of Medicine, Jos University Teachin
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Duncker D, Haghikia A, König T, Hohmann S, Gutleben KJ, Westenfeld R, Oswald H, Klein H, Bauersachs J, Hilfiker-Kleiner D, Veltmann C. Risk for ventricular fibrillation in peripartum cardiomyopathy with severely reduced left ventricular function-value of the wearable cardioverter/defibrillator. Eur J Heart Fail 2014; 16:1331-6. [PMID: 25371320 DOI: 10.1002/ejhf.188] [Citation(s) in RCA: 107] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Revised: 09/16/2014] [Accepted: 09/19/2014] [Indexed: 12/20/2022] Open
Abstract
AIMS The true incidence of life-threatening ventricular tachyarrhythmic events and the risk of sudden cardiac death in the early stage of peripartum cardiomyopathy (PPCM) are still unknown. We aimed to assess the usefulness of the wearable cardioverter/defibrillator (WCD) to bridge a potential risk for life-threatening arrhythmic events in patients with early PPCM, severely reduced left ventricular ejection fraction (LVEF) and symptoms of heart failure. METHODS AND RESULTS Twelve consecutively admitted women with PPCM were included in this single-centre, prospective observational study between September 2012 and September 2013. Patients with LVEF ≤35% were considered to use the WCD for 3 months or even 6 months when considered necessary for LVEF recovery. Nine of the 12 women had a severely reduced LVEF (mean 18.3%) at the time of study enrollment; seven women received a WCD, while two patients refused to wear a WCD. During a median WCD follow-up of 81 days (range 25-345 days), we observed a total of four events of ventricular fibrillation with appropriate and successful WCD shocks in three of the seven women receiving a WCD. No syncope or sudden arrhythmic deaths occurred in women not using the WCD during a median follow-up of 12 months (range 5-15 months). All women showed impressive improvement of LVEF during follow-up. CONCLUSION PPCM patients with severely reduced LVEF have an elevated risk for ventricular tachyarrhythmias early after diagnosis. Therefore, use of the WCD should be considered in all women with early-stage PPCM and severely reduced LVEF during the first 6 months after initiation of heart failure therapy.
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Affiliation(s)
- David Duncker
- Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Strasse 1, Hannover, Germany
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Bloomfield GS, Khazanie P, Morris A, Rabadán-Diehl C, Benjamin LA, Murdoch D, Radcliff VS, Velazquez EJ, Hicks C. HIV and noncommunicable cardiovascular and pulmonary diseases in low- and middle-income countries in the ART era: what we know and best directions for future research. J Acquir Immune Defic Syndr 2014; 67 Suppl 1:S40-53. [PMID: 25117960 PMCID: PMC4133739 DOI: 10.1097/qai.0000000000000257] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
With the advent of effective antiretroviral therapy (ART), HIV is becoming a chronic disease. HIV-seropositive (+) patients on ART can expect to live longer and, as a result, they are at risk of developing chronic noncommunicable diseases related to factors, such as aging, lifestyle, long-term HIV infection, and the potential adverse effects of ART. Although data are incomplete, evidence suggests that even in low- and middle-income countries (LMICs), chronic cardiovascular and pulmonary diseases are increasing in HIV-positive patients. This review summarizes evidence-linking HIV infection to the most commonly cited chronic cardiovascular and pulmonary conditions in LMICs: heart failure, hypertension, coronary artery disease/myocardial infarction, stroke, obstructive lung diseases, and pulmonary arterial hypertension. We describe the observed epidemiology of these conditions, factors affecting expression in LMICs, and key populations that may be at higher risk (ie, illicit drug users and children), and finally, we suggest that strategic areas of research and training intended to counter these conditions effectively. As access to ART in LMICs increases, long-term outcomes among HIV-positive persons will increasingly be determined by a range of associated chronic cardiovascular and pulmonary complications. Actions taken now to identify those conditions that contribute to long-term morbidity and mortality optimize early recognition and diagnosis and implement effective prevention strategies and/or disease interventions are likely to have the greatest impact on limiting cardiovascular and pulmonary disease comorbidity and improving population health among HIV-positive patients in LMICs.
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Affiliation(s)
- Gerald S. Bloomfield
- Division of Cardiology and Duke Clinical Research Institute, Duke University, Durham, NC, USA
- Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Prateeti Khazanie
- Division of Cardiology and Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Alison Morris
- Departments of Medicine and Immunology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Cristina Rabadán-Diehl
- National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Laura A. Benjamin
- Institute of Infection and Global Health, University of Liverpool, Liverpool L69 3BX, UK
- Malawi-Liverpool-Wellcome Major Overseas Clinical Research Programme, College of Medicine, University of Malawi, Blantyre, Malawi
| | - David Murdoch
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Duke University, Durham, NC, USA
| | - Virginia S. Radcliff
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Duke University, Durham, NC, USA
| | - Eric J. Velazquez
- Division of Cardiology and Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Charles Hicks
- Division of Infectious Diseases, Department of Medicine, Duke University, Durham, NC, USA
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Givertz MM, Mann DL. Epidemiology and natural history of recovery of left ventricular function in recent onset dilated cardiomyopathies. Curr Heart Fail Rep 2014; 10:321-30. [PMID: 24014141 DOI: 10.1007/s11897-013-0157-5] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Although the long term prognosis of patients with dilated cardiomyopathy (DCM) remains poor, approximately 25 % of DCM patients with recent onset of heart failure (< 6 months) have a relatively benign clinical course with a spontaneously improvement in symptoms and partial, or in some cases complete, recovery of left ventricular (LV) function. Despite the longstanding recognition of the clinical phenomenon of LV recovery, relatively little attention has been paid to the etiology and natural history of this important group of DCM patients. Accordingly, in the present review we will focus on the epidemiology and natural history of recent onset DCM in patients who undergo spontaneous resolution of symptoms that is accompanied by recovery of LV function.
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Affiliation(s)
- Michael M Givertz
- Cardiovascular Division, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
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Fett JD. Peripartum cardiomyopathy: A puzzle closer to solution. World J Cardiol 2014; 6:87-99. [PMID: 24669290 PMCID: PMC3964190 DOI: 10.4330/wjc.v6.i3.87] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Revised: 12/28/2013] [Accepted: 02/18/2014] [Indexed: 02/06/2023] Open
Abstract
Peripartum cardiomyopathy (PPCM) represents new heart failure in a previously heart-healthy peripartum patient. It is necessary to rule out all other known causes of heart failure before accepting a diagnosis of PPCM. The modern era for PPCM in the United States and beyond began with the report of the National Institutes of Health PPCM Workshop in 2000, clarifying all then-currently known aspects of the disease. Since then, hundreds of publications have appeared, an indication of how devastating this disease can be to young mothers and their families and the urgent desire to find solutions for its cause and better treatment. The purpose of this review is to highlight the important advances that have brought us nearer to the solution of this puzzle, focusing on what we have learned about PPCM since 2000; and what still remains unanswered. Despite many improvements in outcome, we still do not know the actual triggers that initiate the pathological process; but realize that cardiac angiogenic imbalances resulting from complex pregnancy-related immune system and hormonal changes play a key role.
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Citro R, Giudice R, Mirra M, Petta R, Baldi C, Bossone E, Piscione F. Is Tako-tsubo syndrome in the postpartum period a clinical entity different from peripartum cardiomyopathy? J Cardiovasc Med (Hagerstown) 2013; 14:568-75. [DOI: 10.2459/jcm.0b013e32835f1a49] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Abstract
Peripartum cardiomyopathy (PPCM) is a rare form of unexplained cardiac failure of unknown origin, unique to the pregnant woman with highly variable outcome associated with high morbidity and mortality. PPCM is fraught with controversies in its definition, epidemiology, pathophysiology, diagnosis and management. PPCM is frequently under diagnosed, inadequately treated and without a laid down follow-up regimen, thus, the aim of this review. Publications on PPCM were accessed using Medline, Google scholar and Pubmed databases. Relevant materials on PPCM, selected references from internet services, journals, textbooks, and lecture notes on PPCM were also accessed and critically reviewed. PPCM is multifactorial in origin. It is a diagnosis of exclusion and should be based on classic echocardiographic criteria. The outcome of PPCM is also highly variable with high morbidity and mortality rates. Future pregnancies are not recommended in women with persistent ventricular dysfunction because the heart cannot tolerate increased cardiovascular workload associated with the pregnancy. Although, multiparity is associated with PPCM, there is an increased risk of fetal prematurity and fetal loss. PPCM is a rare form of dilated cardiomyopathy of unknown origin, unique to pregnant women. The pathophysiology is poorly understood. Echocardiography is central to diagnosis of PPCM and effective treatment monitoring in patients of PPCM. The outcome is highly variable and related to reversal of ventricular dysfunction.
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Affiliation(s)
- TC Okeke
- Department of Obstetrics and Gynecology, University of Nigeria Teaching Hospital, Enugu, Nigeria
| | - CCT Ezenyeaku
- Department of Obstetrics and Gynecology, Anambra State University Teaching Hospital, Awka, Nigeria
| | - LC Ikeako
- Department of Obstetrics and Gynecology, Anambra State University Teaching Hospital, Awka, Nigeria
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Haghikia A, Podewski E, Libhaber E, Labidi S, Fischer D, Roentgen P, Tsikas D, Jordan J, Lichtinghagen R, von Kaisenberg CS, Struman I, Bovy N, Sliwa K, Bauersachs J, Hilfiker-Kleiner D. Phenotyping and outcome on contemporary management in a German cohort of patients with peripartum cardiomyopathy. Basic Res Cardiol 2013; 108:366. [PMID: 23812247 PMCID: PMC3709080 DOI: 10.1007/s00395-013-0366-9] [Citation(s) in RCA: 220] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Revised: 06/07/2013] [Accepted: 06/12/2013] [Indexed: 12/14/2022]
Abstract
Peripartum cardiomyopathy (PPCM) is a life-threatening heart disease developing towards the end of pregnancy or in the months following delivery in previously healthy women in terms of cardiac disease. Enhanced oxidative stress and the subsequent cleavage of the nursing hormone Prolactin into an anti-angiogenic 16 kDa subfragment emerged as a potential causal factor of the disease. We established a prospective registry with confirmed PPCM present in 115 patients (mean baseline left ventricular ejection fraction, LVEF: 27 ± 9 %). Follow-up data (6 ± 3 months) showed LVEF improvement in 85 % and full recovery in 47 % while 15 % failed to recover with death in 2 % of patients. A positive family history of cardiomyopathy was present in 16.5 %. Pregnancy-associated hypertension was associated with a better outcome while a baseline LVEF ≤ 25 % was associated with a worse outcome. A high recovery rate (96 %) was observed in patients obtaining combination therapy with beta-blocker, angiotensin-converting enzyme (ACE) inhibitors/angiotensin-receptor-blockers (ARBs) and bromocriptine. Increased serum levels of Cathepsin D, the enzyme that generates 16 kDa Prolactin, miR-146a, a direct target of 16 kDa Prolactin, N-terminal-pro-brain-natriuretic peptide (NT-proBNP) and asymmetric dimethylarginine (ADMA) emerged as biomarkers for PPCM. In conclusion, low baseline LVEF is a predictor for poor outcome while pregnancy-induced hypertensive disorders are associated with a better outcome in this European PPCM cohort. The high recovery rate in this collective is associated with a treatment concept using beta-blockers, ACE inhibitors/ARBs and bromocriptine. Increased levels of Cathepsin D activity, miR-146a and ADMA in serum of PPCM patients support the pathophysiological role of 16 kDa Prolactin for PPCM and may be used as a specific diagnostic marker profile.
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Affiliation(s)
- A. Haghikia
- Department of Cardiology and Angiology, Medical School Hannover, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - E. Podewski
- Department of Cardiology and Angiology, Medical School Hannover, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - E. Libhaber
- Department of Medicine, Faculty of Health Sciences, Hatter Cardiovascular Research Institute, University of Cape Town, Cape Town, South Africa
- School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - S. Labidi
- Department of Cardiology and Angiology, Medical School Hannover, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - D. Fischer
- Department of Cardiology and Angiology, Medical School Hannover, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - P. Roentgen
- Department of Cardiology and Angiology, Medical School Hannover, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - D. Tsikas
- Department of Clinical Pharmacology, Medical School Hannover, Hannover, Germany
| | - J. Jordan
- Department of Clinical Pharmacology, Medical School Hannover, Hannover, Germany
| | - R. Lichtinghagen
- Department of Clinical Chemistry, Medical School Hannover, Hannover, Germany
| | - C. S. von Kaisenberg
- Department of Gynecology and Prenatal Medicine, Medical School Hannover, Hannover, Germany
| | - I. Struman
- Unit of Molecular Biology and Genetic Engineering, GIGA, University of Liège, Liège, Belgium
| | - N. Bovy
- Unit of Molecular Biology and Genetic Engineering, GIGA, University of Liège, Liège, Belgium
| | - K. Sliwa
- Department of Medicine, Faculty of Health Sciences, Hatter Cardiovascular Research Institute, University of Cape Town, Cape Town, South Africa
| | - J. Bauersachs
- Department of Cardiology and Angiology, Medical School Hannover, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Denise Hilfiker-Kleiner
- Department of Cardiology and Angiology, Medical School Hannover, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
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Abstract
The last decade has witnessed major advances in our understanding of the epidemiology and pathophysiology of HIV-related cardiovascular disease in sub-Saharan Africa. In this review, we summarise these and discuss clinically relevant advances in diagnosis and treatment. In the Heart of Soweto Study, 10% of patients with newly diagnosed cardiovascular disease were HIV positive, and the most common HIV-related presentations were cardiomyopathy (38%), pericardial disease (13%) and pulmonary arterial hypertension (8%). HIV-related cardiomyopathy is more common with increased immunosuppression and HIV viraemia. With adequate antiretroviral therapy, the prevalence is low. Contributing factors such as malnutrition and genetic predisposition are under investigation. In other settings, pericardial disease is the most common presentation of HIV-related cardiovascular disease (over 40%), and over 90% of pericardial effusions are due to Mycobacterium tuberculosis (TB) pericarditis. HIV-associated TB pericarditis is associated with a greater prevalence of myopericarditis, a lower rate of progression to constriction, and markedly increased mortality. The role of steroids is currently under investigation in the form of a randomised controlled trial. HIV-associated pulmonary hypertension is significantly more common in sub-Saharan Africa than in developed countries, possibly as a result of interactions between HIV and other infectious agents, with very limited treatment options. It has recently been recognised that patients with HIV are at increased risk of sudden death. Infection with HIV is independently associated with QT prolongation, which is more marked with hepatitis C co-infection and associated with a 4.5-fold higher than expected rate of sudden death. The contribution of coronary disease to the overall burden of HIV-associated cardiovascular disease is still low in sub-Saharan Africa.
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Affiliation(s)
- Faisal F Syed
- MRCP Division of Cardiovascular Diseases, Mayo Clinic, 200 1st Street SW, Rochester, MN 55905, USA.
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Sliwa K, Mayosi BM. Recent advances in the epidemiology, pathogenesis and prognosis of acute heart failure and cardiomyopathy in Africa. Heart 2013; 99:1317-22. [PMID: 23680887 DOI: 10.1136/heartjnl-2013-303592] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
This review addresses recent advances in the epidemiology, pathogenesis and prognosis of acute heart failure and cardiomyopathy based on research conducted in Africa. We searched Medline/PubMed for publications on acute decompensated heart failure and cardiomyopathy in Africa for the past 5 years (ie, 1 January 2008 to 31 December 2012). This was supplemented with personal communications with colleagues from Africa working in the field. A large prospective registry has shown that acute decompensated heart failure is caused by hypertension, cardiomyopathy and rheumatic heart disease in 90% of cases, a pattern that is in contrast with the dominance of coronary artery disease in North America and Europe. Furthermore, acute heart failure is a disease of the young with a mean age of 52 years, occurs equally in men and women, and is associated with high mortality at 6 months (∼18%), which is, however, similar to that observed in non-African heart failure registries, suggesting that heart failure has a dire prognosis globally, regardless of aetiology. The molecular genetics of dilated cardiomyopathy, hypertrophic cardiomyopathy and arrhythmogenic right ventricular cardiomyopathy in Africans is consistent with observations elsewhere in the world; the unique founder effects in the Afrikaner provide an opportunity for the study of genotype-phenotype correlations in large numbers of individuals with cardiomyopathy due to the same mutation. Advances in the understanding of the molecular mechanisms of peripartum cardiomyopathy have led to promising clinical trials of bromocriptine in the treatment of peripartum heart failure. The key challenges of management of heart failure are the urgent need to increase the use of proven treatments by physicians, and the control of hypertension in primary care and at the population level.
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Affiliation(s)
- Karen Sliwa
- Hatter Institute for Cardiovascular Research in Africa, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
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Mandal D, Dattaray C, Dutta M, Sarkar G, Sinha P. Peripartum cardiomyopathy coexistent with human immunodeficiency virus: a substantial obstetric jeopardy. Heart Views 2013; 14:26-8. [PMID: 23580922 PMCID: PMC3621221 DOI: 10.4103/1995-705x.107117] [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: 11/04/2022] Open
Abstract
Peripartum cardiomyopathy (PPCM) is a rare cause of pregnancy-related heart failure, which affects a woman during the last months of pregnancy or first months of parturition. Its etiopathogenesis is still unclear. Coexistence of PPCM with human immunodeficiency virus (HIV) has been scarcely analyzed. A low CD4 count is proposed to be one of the predictors of dilated cardiomyopathy in HIV. Here, a pregnant woman with HIV presented with signs of congestive heart failure for the first time during her last trimester. Echocardiography revealed a dilated cardiomyopathy with ejection fraction of 34% which proved the diagnosis of PPCM. She underwent cesarean section for impending previous scar rupture. Her status deteriorated subsequently in spite of all efforts and she succumbed due to ventricular tachycardia. This case necessitates an awareness regarding coexistence of HIV with PPCM and dreaded clinical sequences. Patients suffering from HIV should be treated well and their CD4 count should be improved before conception to avoid such complications in pregnancy.
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Affiliation(s)
- Debasmita Mandal
- Department of Obstetrics and Gynecology, Institute of Post Graduate Medical Education and Research, SSKM Hospital, 244 AJC Bose Road, Kolkata, West Bengal, India
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Schwartz T, Magdi G, Steen TW, Sjaastad I. HIV as a risk factor for cardiac disease in Botswana: a cross-sectional study. Int Health 2012; 4:30-7. [DOI: 10.1016/j.inhe.2011.12.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
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Tibazarwa K, Lee G, Mayosi B, Carrington M, Stewart S, Sliwa K. The 12-lead ECG in peripartum cardiomyopathy. Cardiovasc J Afr 2012; 23:322-9. [PMID: 22337203 PMCID: PMC3734749 DOI: 10.5830/cvja-2012-006] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2011] [Accepted: 01/17/2012] [Indexed: 11/28/2022] Open
Abstract
Background The value of the 12-lead electrocardiogram (ECG) to provide prognostic information in the deadly and disabling syndrome peripartum cardiomyopathy (PPCM) is unknown. Aims To determine the prevalence of major and minor ECG abnormalities in PPCM patients at the time of diagnosis, and to establish whether there are ECG correlates of persistent left ventricular dysfunction and/or clinical stability at six months of follow up, where available. Methods Twelve-lead ECGs were performed at the point of diagnosis on 78 consecutive women presenting with PPCM to two tertiary centres in South Africa and 44 cases (56%) at the six-month follow up. Blinded Minnesota coding identified major ECG abnormalities and minor ECG changes. Results The cohort mainly comprised young women of black African ancestry (90%) [mean age 29 ± 7 years and median body mass index 24.3 (IQR: 22.7–27.5) kg/m2]. The majority of cases (n = 70; 90%) presented in sinus rhythm (mean heart rate 100 ± 21 beats/min). At baseline, at least one ECG abnormality/variant was detected in 96% of cases. Major ECG abnormalities and minor changes were detected in 49% (95% CI: 37–60%) and 62% (95% CI: 51–74%) of cases, respectively; the most common being T-wave changes (59%), p-wave abnormality (29%) and QRS-axis deviation (25%). Of the 44 cases (56%) reviewed at six months, normalisation of the 12-lead ECG occurred in 25%; the most labile ECG features being heart rate (mean reduction of 27 beats/min; p < 0.001) and abnormal QRS axis (36 vs 14%; p = 0.014). On an adjusted basis, major T-wave abnormalities on the baseline 12-lead ECG were associated with lower left ventricular ejection fraction (LVEF) at baseline (average of –9%, 95% CI: –1 to –16; p = 0.03) and at six months (–12%; 95% CI: –4 to –24; p = 0.006). Similarly, baseline ST-segment elevation was also associated with lower LVEF at six months (–25%; 95% CI: –0.7 to –50; p = 0.04). Conclusions In this unique study, we found that almost all women suffering from PPCM had an ‘abnormal’ 12-lead ECG. Pending more definitive studies, the ECG appears to be a useful adjunctive tool in both screening and prognostication in resource-poor settings.
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Affiliation(s)
- Kemi Tibazarwa
- Hatter Institute for Cardiovascular Research in Africa, Department of Medicine, Faculty of Health Sciences, University of Cape Town, South Africa
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