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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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Abstract
PURPOSE OF REVIEW Peripartum cardiomyopathy (PPCM) contributes significantly to maternal morbidity and mortality worldwide. In this review, we describe the present-day epidemiology and current understanding of the pathogenesis of PPCM. We provide an updated approach to diagnosis and management of PPCM, and discuss risk factors and predictors of outcome. RECENT FINDINGS The highest incidences of PPCM have been reported in African, Asian, and Caribbean populations. Contemporary literature supports a 'two-hit' hypothesis, whereby the 'first hit' implies a predisposition, and the 'second hit' refers to an imbalanced peripartal hormonal milieu that results in cardiomyopathy. Whereas a half of patients will have left ventricular (LV) recovery, a tenth do not survive. Clinical findings and special investigations (ECG, echocardiography, cardiac MRI, biomarkers) can be used for risk stratification. Frequent prescription of guideline-directed medical therapy is associated with improved outcomes. SUMMARY Despite advances in elucidating the pathogenesis of PPCM, it remains unclear why only certain women develop the disease. Moreover, even with better diagnostic work-up and management, it remains unknown why some patients with PPCM have persistent LV dysfunction or die. Future research should be aimed at better understanding of the mechanisms of disease and finding new therapies that could improve survival and LV recovery.
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Relation of T Wave Positivity in Lead aVR to Ischemic Etiology of Cardiomyopathy. Am J Cardiol 2022; 180:17-23. [DOI: 10.1016/j.amjcard.2022.06.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 06/08/2022] [Accepted: 06/13/2022] [Indexed: 11/24/2022]
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Cooney R, Scott JR, Mahowald M, Langen E, Sharma G, Kao DP, Davis MB. Heart rate as an early predictor of severe cardiomyopathy and increased mortality in peripartum cardiomyopathy. Clin Cardiol 2022; 45:205-213. [PMID: 35129215 PMCID: PMC8860487 DOI: 10.1002/clc.23782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 01/04/2022] [Accepted: 01/10/2022] [Indexed: 11/14/2022] Open
Abstract
Background Delays in diagnosis of peripartum cardiomyopathy (PPCM) are common and are associated with worse outcomes; however, few studies have addressed methods for improving early detection. Hypothesis We hypothesized that easily accessible data (heart rate [HR] and electrocardiograms [ECGs]) could identify women with more severe PPCM and at increased risk of adverse outcomes. Methods Clinical data, including HR and ECG, from patients diagnosed with PPCM between January 1998 and July 2016 at our institution were collected and analyzed. Linear and logistic regression were used to analyze the relationship between HR at diagnosis and the left ventricular ejection fraction (LVEF) at diagnosis. Outcomes included overall mortality, recovery status, and major adverse cardiac events. Results Among 82 patients meeting inclusion criteria, the overall mean LVEF at diagnosis was 26 ± 11.1%. Sinus tachycardia (HR > 100) was present in a total of 50 patients (60.9%) at the time of diagnosis. In linear regression, HR significantly predicted lower LVEF (F = 30.00, p < .0001). With age‐adjusted logistic regression, elevated HR at diagnosis was associated with a fivefold higher risk of overall mortality when initial HR was >110 beats per minute (adjusted odds ratio 5.35, confidence interval 1.23–23.28), p = .025). Conclusion In this study, sinus tachycardia in women with PPCM was associated with lower LVEF at the time of diagnosis. Tachycardia in the peripartum period should raise concern for cardiomyopathy and may be an early indicator of adverse prognosis.
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Affiliation(s)
- Ryan Cooney
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - John R Scott
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Madeline Mahowald
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Elizabeth Langen
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
| | - Garima Sharma
- Department of Internal Medicine, Hopkins Ciccarone Center for Prevention of Cardiovascular Disease, Division of Cardiology, Baltimore, Maryland, USA
| | - David P Kao
- Department of Internal Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Melinda B Davis
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
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Mansouri MH, Sanei H, Mansouri P, Behnam-Roudsari S, Shemirani H, Zavar R. Evaluating value of positive T wave in lead V1 and TV1 > TV6 pattern in predicting significant coronary artery disease in patients undergoing coronary angiography. ARYA ATHEROSCLEROSIS 2021; 17:1-6. [PMID: 34703483 PMCID: PMC8519619 DOI: 10.22122/arya.v17i0.1927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 06/15/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND The aim of this study was to predict significant coronary artery disease (CAD) in patients undergoing coronary angiography. METHODS In this cross-sectional study, data of 384 patients who underwent angiography during 2015-2017 were reviewed. Electrocardiograms (ECGs) were evaluated in terms of having positive T wave in lead V1 (TV1) described as T wave with amplitude of more than 0.15 mV and angiography records were assessed for presence of significant CAD defined as presence of ≥ 70% internal diameter stenosis in at least one major epicardial coronary artery or more than 50% stenosis in left main artery (LMA). RESULTS Out of 384 patients who participated in this study with mean age of 63.6 ± 10.2 years (40-89 years), 71.6% showed positive TV1 and significant CAD simultaneously and left anterior descending artery (LAD) and left circumflex artery (LCX) lesions were more frequently reported in coronary angiography. Based on chi-square test, the prevalence of significant CAD was obviously more in those with positive TV1 as compared to those without this finding [odds ratio (OR) = 2.74, 95% confidence interval (CI): 1.80-4.19, P < 0.001]. Mann-Whitney test showed significant difference in number of coronary arteries involved in CAD between presence of positive and negative T wave in lead V1 (P < 0.001). Great number of patients with significant CAD had remarkably higher T wave amplitude in lead V1 in comparison to lead V6 (OR = 6.22, 95% CI: 3.14-12.30, P < 0.001). CONCLUSION Positive TV1 and TV1 > TV6 pattern can be considered as a predictor for significant CAD in patients with otherwise normal ECG.
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Affiliation(s)
- Mohammad Hadi Mansouri
- Assistant Professor, Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Hamid Sanei
- Professor, Interventional Cardiology Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Pejman Mansouri
- Resident, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Hasan Shemirani
- Professor, Heart Failure Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Reihaneh Zavar
- Assistant Professor, Cardiac Rehabilitation Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
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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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Acute kidney injury predicts poor left ventricular function for patients with peripartum cardiomyopathy. BMC Cardiovasc Disord 2021; 21:205. [PMID: 33888084 PMCID: PMC8063442 DOI: 10.1186/s12872-021-02021-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 04/14/2021] [Indexed: 11/26/2022] Open
Abstract
Background The aim of this study was to explore the risk factors associated with a poor left ventricular (LV) function among patients with peripartum cardiomyopathy (PPCM) and to determine the influence of acute kidney injury (AKI) on the LV function of the patients. Methods Sixty patients with PPCM were recruited between January 2007 and June 2018, among which 11 had AKI. The participants were divided into two groups, the recovery group (32 cases) and the nonrecovery group (28 cases), with their clinical features, echocardiography and electrocardiogram findings, laboratory results, and treatments compared between groups. We further determined the risk factors associated with nonrecovery and the influence posed by AKI on the LV function of the patients. Results Compared with the patients in the recovery group, those in the nonrecovery group had higher proportions of multiparity [78.6% (22/28) vs. 43.8% (14/32)], function class III– IV heart failure [92.9% (26/28) vs. 71.9% (23/32)], and a higher incidence of AKI [35.7% (10/28) vs. 3.1% (1/32)]. Logistic regression analysis showed that having AKI [odds ratio (OR): 10.556; 95% confidence interval (CI) 1.177–94.654; P = 0.035] and left ventricular ejection fraction (LVEF) < 40% [OR: 4.533; 95% CI 1.118–18.382; P = 0.034] were independently associated with nonrecovery of PPCM. Conclusions The prognosis of patients with PPCM and AKI during hospitalization was poor compared to those without AKI; therefore, clinicians should pay more attention to this phenomenon.
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Duncker D, Pfeffer TJ, Bauersachs J, Veltmann C. ECG and arrhythmias in peripartum cardiomyopathy. Herzschrittmacherther Elektrophysiol 2021; 32:207-213. [PMID: 33791817 DOI: 10.1007/s00399-021-00760-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 03/19/2021] [Indexed: 01/24/2023]
Abstract
Peripartum cardiomyopathy (PPCM) is a rare but life-threatening heart disease, with onset in the last month of pregnancy or in the first months after delivery. Extensive studies on the burden of supraventricular and ventricular arrhythmias are lacking. Patients with PPCM present with electrocardiographic findings typical in acute heart failure. Management of arrhythmias in PPCM depends on the severity and the onset (during pregnancy or after delivery). Studies on the use of the wearable cardioverter-defibrillator in patients with PPCM show a substantial burden of ventricular tachyarrhythmias and sudden death in patients with severely reduced left ventricular function. The aim of the present article is to summarize actual knowledge on electrocardiogram findings, arrhythmias, and sudden cardiac death in patients with PPCM.
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Affiliation(s)
- David Duncker
- Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
| | - Tobias J Pfeffer
- Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Christian Veltmann
- Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
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Ekizler FA, Cay S, Ulvan N, Tekin Tak B, Cetin EHO, Kafes H, Ozeke O, Ozcan F, Topaloglu S, Tufekcioglu O, Aras D. Importance of lead aVR on predicting adverse cardiac events in patients with noncompaction cardiomyopathy. Ann Noninvasive Electrocardiol 2020; 25:e12719. [PMID: 31609051 PMCID: PMC7358825 DOI: 10.1111/anec.12719] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 09/15/2019] [Accepted: 09/17/2019] [Indexed: 12/17/2022] Open
Abstract
Background Noncompaction cardiomyopathy (NCCM) is a relatively rare cardiac abnormality with high rates of mortality and morbidity. T‐wave amplitudes during ventricular repolarization in lead aVR (TaVR) have been reported to be associated with the prognosis of various cardiovascular diseases. This study sought to investigate the prevalence and prognostic role of positive TaVR in patients with NCCM. Methods We evaluated consecutive 161 patients with NCCM (65.8% men, mean age 42.5 ± 15.2 years old). Presentation electrocardiogram was assessed regarding classical parameters as well as T‐wave amplitudes in lead aVR. The primary endpoint was defined as composite lethal arrhythmic events, including sudden cardiac death, ventricular fibrillation, or sustained ventricular tachycardia or appropriate implantable cardioverter–defibrillator shock. Heart failure requiring hospitalization, cardiovascular death, and all‐cause mortality were also investigated as secondary endpoints. Results Patients with positive TaVR showed higher rates for arrhythmic events, hospitalization for heart failure, and death compared with patients without it. In multivariate Cox model, after adjusting for other known clinical and electrocardiographic risk factors, the positive TaVR was found to be a strong independent predictor of primary endpoint (HR: 4.8, 95% CI: 1.2–19.3; p = .025) and all‐cause death (HR: 3.5, 95% CI: 1.0–12.1; p = .045). Conclusion Our findings revealed that positive TaVR is significantly and independently associated with adverse outcomes in NCCM patients. This unique ECG criterion in the often ignored lead provides incremental information beyond what is available with other traditional risk factors.
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Affiliation(s)
| | - Serkan Cay
- Department of Cardiology, Ankara City Hospital, Health Sciences University, Ankara, Turkey
| | - Nedret Ulvan
- Department of Cardiology, Ankara City Hospital, Health Sciences University, Ankara, Turkey
| | - Bahar Tekin Tak
- Department of Cardiology, Ankara City Hospital, Health Sciences University, Ankara, Turkey
| | - Elif Hande Ozcan Cetin
- Department of Cardiology, Ankara City Hospital, Health Sciences University, Ankara, Turkey
| | - Habibe Kafes
- Department of Cardiology, Ankara City Hospital, Health Sciences University, Ankara, Turkey
| | - Ozcan Ozeke
- Department of Cardiology, Ankara City Hospital, Health Sciences University, Ankara, Turkey
| | - Firat Ozcan
- Department of Cardiology, Ankara City Hospital, Health Sciences University, Ankara, Turkey
| | - Serkan Topaloglu
- Department of Cardiology, Ankara City Hospital, Health Sciences University, Ankara, Turkey
| | - Omac Tufekcioglu
- Department of Cardiology, Ankara City Hospital, Health Sciences University, Ankara, Turkey
| | - Dursun Aras
- Department of Cardiology, Ankara City Hospital, Health Sciences University, Ankara, Turkey
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Siren M, Koivula K, Eskola MJ, Martiskainen M, Huhtala H, Laurikka J, Mikkelsson J, Järvelä K, Niemelä KO, Punkka O, Karhunen PJ, Nikus KC. The prognostic significance of a positive or isoelectric T wave in lead aVR in patients with acute coronary syndrome and ischemic ECG changes in the presenting ECG - Long-term follow-up data of the TACOS study. J Electrocardiol 2020; 60:131-137. [PMID: 32361088 DOI: 10.1016/j.jelectrocard.2020.04.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 04/03/2020] [Accepted: 04/11/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND A positive T wave in lead aVR (aVRT+) is an independent prognostic predictor of cardiovascular mortality in the general population as well as in cardiovascular disease. SUBJECTS AND METHODS We evaluated the prognostic impact of aVRT+ in an ECG recorded as close to hospital discharge as possible in acute coronary syndrome patients (n = 527). We divided the patients into three categories based on the findings in the admission ECG: ST elevation, global ischemia and other ST/T changes. RESULTS In the whole study population, and in all the three ECG subgroups, the 10-year all-cause mortality rate was higher in the aVRT+ group than in the aVRT- group. In Cox regression analysis, the age and gender adjusted hazard ratio (HR) for aVRT+ to predict all-cause mortality in the whole study population was 1.43 (95% confidence interval [CI] 1.12-1.83; p = 0.004). To predict cardiovascular mortality, the age and gender adjusted HR for aVRT+ was 1.54 (95% CI 1.14-2.07; p = 0.005) in the whole study population and 2.07 (95% CI 1.07-4.03; p = 0.032) in the category with other ST/T changes. CONCLUSION In ACS patients with or without ST elevation, but with ischemic ST/T changes in their presenting ECG, a positive or isoelectric T wave in lead aVR in an ECG recorded in the subacute in-hospital stage is associated with all-cause and cardiovascular mortality during long-term follow-up. Clinicians should pay attention to this simple ECG finding at hospital discharge.
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Affiliation(s)
- Marko Siren
- Faculty of Medicine and Health Technology, Tampere University, Finland.
| | - Kimmo Koivula
- Faculty of Medicine and Health Technology, Tampere University, Finland; South-Karelia Central Hospital, Finland
| | | | | | - Heini Huhtala
- Faculty of Social Sciences, Tampere University, Finland
| | | | | | - Kati Järvelä
- Heart Center, Tampere University Hospital, Finland
| | | | - Olli Punkka
- Faculty of Medicine and Health Technology, Tampere University, Finland
| | - Pekka J Karhunen
- Faculty of Medicine and Health Technology, Tampere University, Finland; Fimlab Laboratories Tampere University Hospital, Tampere, Finland
| | - Kjell C Nikus
- Faculty of Medicine and Health Technology, Tampere University, Finland; Heart Center, Tampere University Hospital, Finland
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Hoevelmann J, Hähnle L, Hähnle J, Sliwa K, Viljoen C. Detection and management of arrhythmias in peripartum cardiomyopathy. Cardiovasc Diagn Ther 2020; 10:325-335. [PMID: 32420115 DOI: 10.21037/cdt.2019.05.03] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Peripartum cardiomyopathy (PPCM) is an idiopathic dilated cardiomyopathy, in which previously healthy women present with heart failure secondary to left ventricular (LV) systolic dysfunction during the last months of pregnancy or up to 5 months postpartum. PPCM occurs worldwide. The incidence seems to be increasing, possibly due to increasing awareness of the condition and diagnosis thereof. Women diagnosed with PPCM present with symptoms and signs of heart failure, thromboembolism or arrhythmia. Although the incidence of arrhythmias in this condition is not well documented, patients with PPCM often have rhythm disturbances. Indeed, life-threating arrhythmias contribute significantly to sudden cardiac death (SCD) in this population, especially when patients have poor systolic function. In this review, we summarize the evidence on atrial and ventricular arrhythmias in PPCM, as detected by various diagnostic modalities. Furthermore, we summarize the management of arrhythmias in PPCM, as recommended by contemporary guidelines.
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Affiliation(s)
- Julian Hoevelmann
- Hatter Institute for Cardiovascular Research in Africa, University of Cape Town, Cape Town, South Africa.,Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Lina Hähnle
- Hatter Institute for Cardiovascular Research in Africa, University of Cape Town, Cape Town, South Africa
| | - Julia Hähnle
- Hatter Institute for Cardiovascular Research in Africa, University of Cape Town, Cape Town, South Africa
| | - Karen Sliwa
- Hatter Institute for Cardiovascular Research in Africa, University of Cape Town, Cape Town, South Africa.,Division of Cardiology, University of Cape Town, Cape Town, South Africa
| | - Charle Viljoen
- Hatter Institute for Cardiovascular Research in Africa, University of Cape Town, Cape Town, South Africa.,Division of Cardiology, University of Cape Town, Cape Town, South Africa
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Ricke-Hoch M, Pfeffer TJ, Hilfiker-Kleiner D. Peripartum cardiomyopathy: basic mechanisms and hope for new therapies. Cardiovasc Res 2019; 116:520-531. [DOI: 10.1093/cvr/cvz252] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 07/17/2019] [Accepted: 10/04/2019] [Indexed: 12/28/2022] Open
Abstract
Abstract
Peripartum cardiomyopathy (PPCM) is a life-threatening cardiomyopathy characterized by acute or slow progression of left ventricular (LV) systolic dysfunction (LV ejection fraction of <45%) late in pregnancy, during delivery, or in the first postpartum months, in women with no other identifiable causes of heart failure. PPCM patients display variable phenotypes and risk factor profiles, pointing to involvement of multiple mechanisms in the pathogenesis of the disease. The higher risk for PPCM in women with African ancestry, the prevalence of gene variants associated with cardiomyopathies, and the high variability in onset and disease progression in PPCM patients also indicate multiple mechanisms at work. Experimental data have shown that different factors can induce and drive PPCM, including inflammation and immunity, pregnancy hormone impairment, catecholamine stress, defective cAMP-PKA, and G-protein-coupled-receptor signalling, and genetic variants. However, several of these mechanisms may merge into a common major pathway, which includes unbalanced oxidative stress and the cleavage of the nursing hormone prolactin (PRL) into an angiostatic, pro-apoptotic, and pro-inflammatory 16 kDa-PRL fragment, resulting in subsequent vascular damage and heart failure. Based on this common pathway, potential disease-specific biomarkers and therapies have emerged. Despite commonalities, the variation in aetiology and mechanisms poses challenges for the diagnosis, treatment, and management of the disease. This review summarizes current knowledge on the clinical presentation of PPCM in the context of recent experimental research. It discusses the challenge to develop disease-specific biomarkers in the context of rapid changing physiology in the peripartum phase, and outlines possible future treatment and management strategies for PPCM patients.
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Affiliation(s)
- Melanie Ricke-Hoch
- Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg Str. 1, 30625 Hannover, Germany
| | - Tobias J Pfeffer
- Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg Str. 1, 30625 Hannover, Germany
| | - Denise Hilfiker-Kleiner
- Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg Str. 1, 30625 Hannover, Germany
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13
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12‑lead ECG as an emerging risk stratifier in peripartum cardiomyopathy. Int J Cardiol 2019; 293:185. [DOI: 10.1016/j.ijcard.2019.05.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Accepted: 05/15/2019] [Indexed: 11/20/2022]
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14
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Ekizler FA, Cay S, Kafes H, Ozeke O, Ozcan F, Topaloglu S, Temizhan A, Aras D. The prognostic value of positive T wave in lead aVR: A novel marker of adverse cardiac outcomes in peripartum cardiomyopathy. Ann Noninvasive Electrocardiol 2019; 24:e12631. [PMID: 30653267 DOI: 10.1111/anec.12631] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 10/28/2018] [Accepted: 11/03/2018] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Peripartum cardiomyopathy (PPCM) is an uncommon complication of pregnancy. Clinical courses of PPCM are markedly heterogeneous. Positive T waves in lead aVR (TaVR) are shown to be associated with adverse cardiac events in several cardiovascular diseases. We aimed to investigate the prevalence and prognostic role of positive TaVR in patients with PPCM. METHODS A total of 82 patients (mean age 29.1 ± 6.3 years) with the diagnosis of PPCM were enrolled. Presentation electrocardiogram (ECG) was investigated for presence of a positive TaVR. The median follow-up duration was 67.0 months. The primary endpoint was defined as composite cardiac events, including cardiac death, arrhythmic events, or persistent left ventricular systolic dysfunction. RESULTS Patients with positive T wave in lead aVR showed higher rates for persistent left ventricular systolic dysfunction, arrhythmic events, and cardiac death compared to patients without it. In multivariate logistic regression analysis, after adjusting for other confounding factors, the presence of positive TaVR was found to be as an independent and strong predictor of primary composite endpoint (odds ratio 6.21, 95% CI 1.45-26.51; p = 0.014). In Kaplan-Meier survival analysis, both primary and secondary endpoints occurred more frequently in the positive TaVR group. Using the cut-off level of 0.25 mV, T-wave amplitude in lead aVR predicted primary endpoint with a sensitivity of 100% and specificity of 100%. CONCLUSION Positive T wave in lead aVR, as a simple and feasible electrocardiographic marker, seems to be a novel predictor of adverse cardiovascular outcomes in patients with PPCM.
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Affiliation(s)
- Firdevs Aysenur Ekizler
- Department of Cardiology, Turkiye Yuksek Ihtisas Training and Research Hospital, Ankara, Turkey
| | - Serkan Cay
- Department of Cardiology, Turkiye Yuksek Ihtisas Training and Research Hospital, Ankara, Turkey
| | - Habibe Kafes
- Department of Cardiology, Turkiye Yuksek Ihtisas Training and Research Hospital, Ankara, Turkey
| | - Ozcan Ozeke
- Department of Cardiology, Turkiye Yuksek Ihtisas Training and Research Hospital, Ankara, Turkey
| | - Firat Ozcan
- Department of Cardiology, Turkiye Yuksek Ihtisas Training and Research Hospital, Ankara, Turkey
| | - Serkan Topaloglu
- Department of Cardiology, Turkiye Yuksek Ihtisas Training and Research Hospital, Ankara, Turkey
| | - Ahmet Temizhan
- Department of Cardiology, Turkiye Yuksek Ihtisas Training and Research Hospital, Ankara, Turkey
| | - Dursun Aras
- Department of Cardiology, Turkiye Yuksek Ihtisas Training and Research Hospital, Ankara, Turkey
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