Long-Term Cardiac Function After Peripartum Cardiomyopathy and Preeclampsia: A Danish Nationwide, Clinical Follow-Up Study Using Maximal Exercise Testing and Cardiac Magnetic Resonance Imaging

Connecting the Dots: Exploring the Interplay Between Preeclampsia and Peripartum Cardiomyopathy

Preeclampsia and peripartum cardiomyopathy (PPCM) are significant obstetric problems that can arise during or after pregnancy. Both are known to be causes of maternal mortality and morbidity. Several recent studies have suggested a link between preeclampsia and the pathophysiology of PPCM. However, the common thread that connects the two has yet to be thoroughly and fully articulated. Here, we investigate the complex dynamics of preeclampsia and PPCM in this review. Our analysis focuses mainly on inflammatory and immunological responses, endothelial dysfunction as a shared pathway, and potential genetic predisposition to both diseases. To begin, we will look at how excessive inflammatory and immunological responses can lead to clinical symptoms of both illnesses, emphasizing the role of proinflammatory cytokines and immune cells in modifying vascular and tissue responses. Second, we consider endothelial dysfunction to be a crucial point at which endothelial damage and activation contribute to pathogenesis through increased vascular permeability, vascular dysfunction, and thrombus formation. Finally, we examine recent information suggesting genetic predispositions to preeclampsia and PPCM, such as genetic variants in genes involved in the management of blood pressure, the inflammatory response, and heart structural integrity. With this synergistic study, we seek to encourage more research and creative therapy solutions by emphasizing the need for an interdisciplinary approach to understanding and managing the connection between preeclampsia and PPCM.

Temporal patterns of pre- and post-natal target organ damage associated with hypertensive pregnancy: a systematic review

AIMS

Hypertensive pregnancy is associated with increased risks of developing a range of vascular disorders in later life. Understanding when hypertensive target organ damage first emerges could guide optimal timing of preventive interventions. This review identifies evidence of hypertensive target organ damage across cardiac, vascular, cerebral, and renal systems at different time points from pregnancy to postpartum.

METHODS AND RESULTS

Systematic review of Ovid/MEDLINE, EMBASE, and ClinicalTrials.gov up to and including February 2023 including review of reference lists. Identified articles underwent evaluation via a synthesis without meta-analysis using a vote-counting approach based on direction of effect, regardless of statistical significance. Risk of bias was assessed for each outcome domain, and only higher quality studies were used for final analysis. From 7644 articles, 76 studies, including data from 1 742 698 pregnancies, were identified of high quality that reported either blood pressure trajectories or target organ damage during or after a hypertensive pregnancy. Left ventricular hypertrophy, white matter lesions, proteinuria, and retinal microvasculature changes were first evident in women during a hypertensive pregnancy. Cardiac, cerebral, and retinal changes were also reported in studies performed during the early and late post-partum period despite reduction in blood pressure early postpartum. Cognitive dysfunction was first reported late postpartum.

CONCLUSION

The majority of target organ damage reported during a hypertensive pregnancy remains evident throughout the early and late post-partum period despite variation in blood pressure. Early peri-partum strategies may be required to prevent or reverse target organ damage in women who have had a hypertensive pregnancy.

Associations between extreme temperature exposure and hypertensive disorders in pregnancy: a systematic review and meta-analysis

BACKGROUND

Hypertensive disorders in pregnancy (HDP) are a major cause of maternal mortality and morbidity. Recent studies indicated that pregnant women are the most vulnerable populations to ambient temperature influences, but it affected HDP with inconsistent conclusions. Our objective is to systematically review whether extreme temperature exposure is associated with a changed risk for HDP.

METHOD

We searched PubMed, EMBASE, Web of Science and Cochrane Library databases. We included cohort or case control studies examining the association between extreme temperature exposure before or during pregnancy and HDP. Heat sources such as saunas and hot baths were excluded. We pooled the odds ratio (OR) to assess the association between extreme temperature exposure and preeclampsia or eclampsia.

RESULTS

Fifteen studies involving 4,481,888 patients were included. Five studies were included in the meta-analysis. The overall result demonstrated that in the first half of pregnancy, heat exposure increases the risk of developing preeclampsia or eclampsia and gestational hypertension, and cold exposure decreases the risk. The meta-analysis revealed that during the first half of pregnancy, heat exposure increased the risk of preeclampsia or eclampsia (OR 1.54, 95% confidence interval (CI): 1.10, 2.15), whereas cold exposure decreased the risk (OR 0.90, 95% CI: 0.84, 0.97).

CONCLUSION

The ambient temperature is an important determinant for the development of HDP, especially for preeclampsia or eclampsia. The effects of extreme temperatures may be bidirectional during the different trimesters of pregnancy, which should be evaluated by future studies. This review provided hints of temperature regulation in HDP administration.

Cardiorespiratory fitness in women after severe pre-eclampsia

AIMS

To objectively study cardiorespiratory fitness (CRF) and physical activity (PA) and to evaluate limiting factors of exercise intolerance associated with poor CRF after severe pre-eclampsia.

METHODS

In this single-centre, cross-sectional study, CRF was measured as peak oxygen uptake (VO2peak) during a cardiopulmonary exercise test (CPET) on a treadmill in women 7 years after severe pre-eclampsia. Ninety-six patients and 65 controls were eligible to participate. Cardiac output (CO) was measured by impedance cardiography. PA was measured using accelerometers.

RESULTS

In 62 patients and 35 controls (mean age 40 ± 3 years), the VO2peak (in mL·kg-1·min-1) values were 31.4 ± 7.2 and 39.1 ± 5.4, respectively (p<0.01). In the patients, the COpeak was (9.6 L·min-1), 16% lower compared to controls (p<0.01). Twelve patients (19%) had a cardiac limitation to CPET. Twenty-three (37%) patients and one (3%) control were classed as unfit, with no cardiopulmonary limitations. The patients demonstrated 25% lower PA level (in counts per minute; p<0.01) and 14% more time being sedentary (p<0.01), compared with the controls. Twenty-one patients (34%) compared with four (17%) controls did not meet the World Health Organization's recommendations for PA (p=0.02). Body mass index and PA level accounted for 65% of the variability in VO2peak.

CONCLUSION

Significantly lower CRF and PA levels were found in patients on long-term follow-up after severe pre-eclampsia. CPET identified cardiovascular limitations in one third of patients. One third appeared unfit, with adiposity and lower PA levels. These findings highlight the need for clinical follow-up and exercise interventions after severe pre-eclampsia.

Prognostic Value of Cardiac MRI Late Gadolinium Enhancement in Patients with Peripartum Cardiomyopathy: A Retrospective Study

A significant proportion of peripartum cardiomyopathy (PPCM) patients experience persistent heart failure even death, the underneath reason of non-recovery may attribute to the myocardial tissue damage. This study aims to explore the prognostic value of cardiac MRI late gadolinium enhancement (LGE) in women with PPCM, and further establish a predictive model for poor outcomes. Eighty-four consecutively diagnosed women with PPCM underwent cardiac MRI between January 2010 to December 2019. A combined endpoint of poor outcomes (death, New York Heart Association functional class III/IV, heart transplantation or a persistently reduced left ventricular ejection fraction [LVEF)] and complete recovery [an LVEF ≥50%]) were defined. Least absolute shrinkage and selection operator regression and nomogram model were performed to demonstrate prognostic value of cardiac MRI. Higher occurrence of LGE was detected in PPCM women with reached poor outcomes than those who completely recovered (odds ratio: 4.4, 95% CI: 2.6 to 7.5, P<0.001) . PPCM women with LGE+ were more likely to reach combined endpoint of poor outcomes than those with LGE- (odds ratio: 8.2, 95% CI: 1.1 to 59.2, P=0.003). The poor outcome-free rates PPCM women in the group with LGE were lower than those without LGE (log-rank χ²=13.5, P<0.001). LGE presence (hazard ratio [HR]=10.7, 95% CI: 1.38-83.5, P<0.05) and LGE extent (HR=1.2, 95% CI: 1.0-1.3, P<0.05) were prognostic factors for poor outcomes. The predictive nomogram model on LGE showed good discrimination (C index=0.8, 95% CI: 0.6-0.9).Cardiac MRI LGE was an incremental predictive modality for poor outcomes and risk stratification in women with PPCM.

Meta-Analysis of Long-Term (>1 Year) Cardiac Outcomes of Peripartum Cardiomyopathy

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.

The outcome of peripartum cardiomyopathy patients-single center experience

OBJECTIVE

Peripartum cardiomyopathy (PPCM) diagnosis made by excluding identifiable causes of heart failure (HF) and occurs end of the pregnancy or during the postpartum period of five months. It presents a clinical HF spectrum with left ventricular systolic dysfunction.

BACKGROUND

The purpose of this study is to retrospectively evaluate the clinical characteristics, cardiac magnetic resonance (CMR) imaging features, and end-points consisting of left ventricle recovery, left ventricular assist device implantation, heart transplantation, and all-cause mortality.

METHOD

Outpatient HF records between 2008 to 2021 were screened. Thirty-seven patients were defined as PPCM. Twenty-five patients had CMR evaluation at the time of diagnosis, and six patients were re-evaluated with CMR.

RESULTS

The mean age was 30.5 ± 5.6 years, and the mean LVEF was 28.2% ± 6.7%. In 13(35.7%) patients, LVEF recovered during the follow-up course. The median recovery time was 281(IQR [78-358]) days. LVEF on CMR was 35.3 ± 10.5, and three patients exhibited late gadolinium enhancement(LGE) patterns. Sub-endocardial and mid-wall uptake pattern types were detected. 18(75%) patients met the Petersen left ventricle non-compaction cardiomyopathy(LVNC) criteria. Patients with NC/C ratio lower than 2.3 had lower LVEDVi and LVESVi (124.9 ± 35.4, 86.4 ± 7.5, p = .003; 86.8 ± 34.6, 52.6 ± 7.6, p = .006), respectively. The median follow-up time was 2129 (IQR [911-2634]) days. The primary endpoint-free 1-year survival was 88.9% (event rate 11.1%), and 5-year survival was 75.7% (event rate 24.3%).

CONCLUSION

In a retrospective cohort of PPCM patients, 35.7% of patients' LVEF recovered, and the primary end-point of free-5-year survival was 75%. Twenty-five patients were assessed with CMR; three of four met the Petersen CMR-derived LVNC at initial evaluation.

Association between Cardiorespiratory Fitness and Hypertensive Disorders of Pregnancy: A Systematic Review and Meta-Analysis

Hypertensive disorders of pregnancy (HDP) are associated with future cardiovascular disease (CVD), which may be mediated by diminished cardiorespiratory fitness (CRF). In this systematic review and meta-analysis, we summarize evidence linking CRF with HDP before, during, and after pregnancy. We searched relevant databases to identify observational or randomized studies that measured CRF (VO2 max or peak, VO2 at anaerobic threshold, or work rate at peak VO2) in women with and without HDP. We pooled results using random effects models. Fourteen studies (n = 2406 women) reporting on CRF before, during, and after pregnancy were included. Before pregnancy, women who developed HDP had lower CRF (e.g., VO2max < 37 vs. ≥37 mL O2/min) than those without HDP (two studies, 811 women). VO2max at 14−18 weeks of pregnancy was marginally lower among women who developed preeclampsia vs. normotensive women (three studies, 275 women; mean difference 0.43 mL/kg/min [95% CI 0.97, 0.10]). Postpartum, there was a trend towards lower VO2peak in women with previous preeclampsia (three studies, 208 women; 0.26 mL/kg/min [−0.54, 0.02]). While exploratory, our findings raise the possibility that CRF can identify women at risk for HDP, and furthermore, that HDP confers a hit to a woman’s cardiorespiratory reserve.

Noninvasive Cardiac Imaging in Formerly Preeclamptic Women for Early Detection of Subclinical Myocardial Abnormalities: A 2022 Update

Preeclampsia is a maternal hypertensive disease, complicating 2–8% of all pregnancies. It has been linked to a 2–7-fold increased risk for the development of cardiovascular disease, including heart failure, later in life. A total of 40% of formerly preeclamptic women develop preclinical heart failure, which may further deteriorate into clinical heart failure. Noninvasive cardiac imaging could assist in the early detection of myocardial abnormalities, especially in the preclinical stage, when these changes are likely to be reversible. Moreover, imaging studies can improve our insights into the relationship between preeclampsia and heart failure and can be used for monitoring. Cardiac ultrasound is used to assess quantitative changes, including the left ventricular cavity volume and wall thickness, myocardial mass, systolic and diastolic function, and strain. Cardiac magnetic resonance imaging may be of additional diagnostic value to assess diffuse and focal fibrosis and perfusion. After preeclampsia, sustained elevated myocardial mass along with reduced myocardial circumferential and longitudinal strain and decreased diastolic function is reported. These findings are consistent with the early phases of heart failure, referred to as preclinical (asymptomatic) or B-stage heart failure. In this review, we will provide an up-to-date overview of the potential of cardiac magnetic resonance imaging and echocardiography in identifying formerly preeclamptic women who are at high risk for developing heart failure. The potential contribution to early cardiac screening of women with a history of preeclampsia and the pros and cons of these imaging modalities are outlined. Finally, recommendations for future research are presented.

Advancement in Current Therapeutic Modalities in Postpartum Cardiomyopathy

Pregnancy is considered one of the most delicate conditions for the woman and her fetus, rendering physiological stress on her body. Sometimes, this leads to unwelcomed incidences of certain systemic disorders which further complicate the course of pregnancy. Cardiovascular conditions associated with pregnancy have major morbidity amongst the general population. Peripartum cardiomyopathy, one such condition associated with cardiac dysfunction during pregnancy, is one of the major causes of increased morbidity and mortality in pregnant women. It has been the leading cause of non-obstetric maternal mortality. Due to the stress on the cardiovascular system, further functioning of the body in the milieu gets compromised and thus, the occurrence of fetomaternal mortality is not rare in the prognosis of this condition. Certain studies have noted not only familial but also geographical variations in the prevalence of peripartum cardiomyopathy in certain areas. Although the occurrence of the condition is quite common, there still needs to be a better understanding of this topic for avoiding the abysmal prognosis of this pathology. A peculiar presentation on the electrogram is needed to make an accurate diagnosis of the condition. The therapeutic options of this condition, particularly incline towards medical management. Various new drugs have been formulated and are in clinical trials for testing their effectiveness. Bromocriptine therapy, along with the neoadjuvant combination of anticoagulant drugs and non-pharmacological measures, makes a good treatment regimen that helps avert the progressive pathology. In this article, we discuss the knowledge regarding the etiology, factors contributing to the severity, pathogenesis, treatment options, and the particular outcomes of the therapy.

Pregnancy Complications Lead to Subclinical Maternal Heart Dysfunction—The Importance and Benefits of Follow-Up Using Speckle Tracking Echocardiography

Pregnancy complications such as gestational diabetes (GDM) and hypertensive disorders of pregnancy (HDP) are frequent and influence not only fetal outcomes but also the maternal cardiac function. GDM and HDP may act as a proxy for increased metabolic and cardiovascular risk later in life. Speckle tracking echocardiography (STE) is a relatively new imaging technique that provides more sensitive assessment than conventional echocardiography of the maternal cardiac function. Recent research suggests that STE can be used during pregnancy and postpartum as a useful method of early detection of subclinical maternal cardiac changes related to pregnancy complications, such as GDM and HDP, and as an indicator for future maternal cardiovascular disorders. The aim of this review was to underline the current value of STE in the follow-up protocol of high-risk pregnant women, as a mean for pre- and postpartum monitoring. A review of the literature was conducted in the PubMed database to select relevant articles regarding the association of STE changes and HDP or GDM in the prenatal and postpartum maternal evaluations. Both GDM and HDP are associated with subtle myocardial changes in shape, size and function; these preclinical cardiac changes, often missed by conventional evaluation, can be detected using STE. Left ventricular global circumferential strain might be an important predictor of maternal cardiovascular disorders and might help to define a high-risk group that requires regular monitoring later in life and timely intervention.

Severe Maternal Morbidity and Long-Term Risk of Cardiovascular Hospitalization

BACKGROUND

Severe maternal morbidity is rising, yet the association with cardiovascular disease is not clear. We examined the risk of cardiovascular hospitalization up to 3 decades after having a pregnancy complicated by severe maternal morbidity.

METHODS

We analyzed a longitudinal cohort of 1 336 846 women who were pregnant between 1989 and 2019 in Quebec, Canada. The main exposure measure was severe maternal morbidity in any pregnancy, including severe preeclampsia, acute renal failure, sepsis, and other life-threatening conditions. Using time-varying Cox regression models, we compared the adjusted risk of hospitalization for cardiovascular disease up to 3 decades after pregnancy for women with severe maternal morbidity relative to women without severe morbidity.

RESULTS

Five percent of women had severe maternal morbidity. Overall, there were 68 287 cardiovascular hospitalizations during 21 725 672 person-years of follow-up in the cohort. Compared with no morbidity, women with any severe morbidity had a greater risk of cardiovascular hospitalization (hazard ratio [HR], 1.77 [95% CI, 1.72-1.82]). The association was the greatest within the first year of delivery (HR, 4.42 [95% CI, 3.77-5.19]) but persisted beyond 15 years (HR, 1.44 [95% CI, 1.37-1.51]). Having a cardiac complication (HR, 5.37 [95% CI, 4.65-6.20]), cerebrovascular accident (HR, 3.82 [95% CI, 2.94-4.96]), or acute renal failure (HR, 2.60 [95% CI, 2.15-3.14]) during pregnancy was strongly associated with future cardiovascular hospitalization.

CONCLUSIONS

Women with severe maternal morbidity have a greater risk of cardiovascular disease after pregnancy, both in the short and long term. These women may benefit from active surveillance for cardiovascular disease.

Peripartum Cardiomyopathy: Diagnostic and Prognostic Value of Cardiac Magnetic Resonance in the Acute Stage

This study aimed to evaluate the diagnostic and prognostic value of cardiac magnetic resonance in acute peripartum cardiomyopathy (PPCM). A total of 17 patients with PPCM in the acute stage and 15 healthy controls were retrospectively analyzed regarding myocardial function, edema, late gadolinium enhancement (LGE), and T1 and T2 mappings (T1, T2). Echocardiographic follow-ups were performed. Functional recovery was defined as a left ventricular ejection fraction (LVEF) of ≥50%. Patients with PPCM displayed biventricular dysfunction with reduced myocardial strain parameters and left ventricular and atrial dilatation, as well as diffuse myocardial edema (T2 signal intensity ratio: 2.10 ± 0.34 vs. 1.58 ± 0.21, p < 0.001; T1: 1070 ± 51 ms vs. 980 ± 28 ms, p = 0.001; T2: 63 ± 5 ms vs. 53 ± 2 ms, p < 0.001). Visual myocardial edema was present in 10 patients (59%). LGE was positive in 2 patients (12%). A total of 13 patients (76%) showed full LVEF recovery. The absence of visual myocardial edema and impairment of strain parameters were associated with delayed LVEF recovery. Multivariable Cox regression analysis revealed global longitudinal strain as an independent prognostic factor for LVEF recovery. In conclusion, biventricular systolic dysfunction with diffuse myocardial edema seems to be present in acute PPCM. Myocardial edema and strain may have prognostic value for LVEF recovery.

Exercise Ventricular Reserve Among Women With a History of Peripartum Cardiomyopathy

Peripartum cardiomyopathy (PPCM) is associated with highly variable clinical outcomes. Small series suggest postpartum variation in exercise capacity and ventricular reserve. We describe limitations in exercise capacity and/or ventricular reserve in asymptomatic women who had recovered from PPCM and underwent a detailed physiologic assessment by cardiopulmonary exercise testing. (Level of Difficulty: Intermediate.)

Differences in epidemiology of patients with preeclampsia between China and the US (Review)

Preeclampsia (PE) is a complex complication that occurs during pregnancy. Studies indicated that morbidity from PE exhibits marked variations among geographical areas. Disparities in the incidence of PE between China and the US may be due to differences in ethnicity and genetic susceptibility, maternal age, sexual culture, body mass index, diet, exercise, multiple pregnancies and educational background. These epidemiological differences may give rise to differences between the two countries in terms of diagnostic and therapeutic criteria for PE. PE may be largely attributed to susceptibility genes and lifestyles, such as diet, body mass index and cultural norms regarding sexual relationships. The epidemiologic differences of patients with PE between the two countries indicated that appropriate prevention plans for PE require to be developed according to local conditions.

Preeclampsia Emerging as a Risk Factor of Cardiovascular Disease in Women

The objective of this literature review was to explore the long-term cardiovascular effects of preeclampsia in women. The primary goal was to determine which organs were most commonly affected in this population. Although it was previously believed that preeclampsia is cured after the delivery of the fetus and the placenta current evidence supports an association between preeclampsia and cardiovascular disease later in life, many years after the manifestation of this hypertensive pregnancy related disorder. Therefore preeclampsia may be emerging as a novel cardiovascular risk factor for women, which requires long-term follow up.

Biomarkers and Their Relation to Cardiac Function Late After Peripartum Cardiomyopathy

BACKGROUND

Angiogenic imbalance involving the placental protein soluble Fms-like tyrosine kinase-1 (sFlt-1) and cleavage of the nursing-hormone prolactin by the enzyme cathepsin D (CD) both play a role in the pathogenesis of peripartum cardiomyopathy (PPCM). We hypothesized that angiogenic imbalance and increased activity of CD have a long-lasting impact in women with PPCM.

METHODS AND RESULTS

A nationwide Danish cohort of women with PPCM (PPCM group, n = 28), age matched women with previous preeclampsia (n = 28) and uncomplicated pregnancies (n = 28) participated in a follow-up study including biomarker analysis, exercise testing and cardiac magnetic resonance imaging. The median time to follow-up was 91 months (range 27-137 months) for the PPCM group. Levels of sFlt-1, placental growth factor, N-terminal pro-natriuretic brain peptide, and copeptin were all significantly higher in the PPCM group. More women in the PPCM group had detectable CD activity (68%) compared with the preeclampsia group (29%) and uncomplicated pregnancies group (36%) (P = .0002). Levels of angiogenic factors and biomarkers correlated inversely with maximal exercise capacity and cardiac functional parameters assessed with cardiac magnetic resonance imaging.

CONCLUSIONS

Women with PPCM had higher biomarker levels and CD activity up to 7 years after diagnosis. Higher biomarker levels correlated inversely with maximal exercise capacity and markers of cardiac dysfunction suggesting that persistent angiogenic imbalance and increased CD activity is associated with residual cardiac dysfunction.

A Case-Control Study of Peripartum Cardiomyopathy Using the Rochester Epidemiology Project

Background:

The incidence of peripartum cardiomyopathy (PPCM) is known through referral center databases that may be affected by referral, misclassification, and other biases. We sought to determine the community-based incidence and natural history of PPCM using the Rochester Epidemiology Project.

Methods and Results:

Incident cases of PPCM occurring between January 1, 1970, and December 31, 2014, were identified in Olmsted County, Minnesota. A total of 15 PPCM cases were confirmed yielding an incidence of 20.3 cases per 100,000 live births in Olmsted County, Minnesota. Clinical information, disease characteristics, and outcomes were extracted from medical records in a 27-county region of the Rochester Epidemiology Project including Olmsted County and matched in a 1:2 ratio with pregnant women without PPCM. A total of 48 women were identified with PPCM in the expanded 27-county region. There was 1 death and no transplants over a median of 7.3 years of follow-up. Six of the 23 women with subsequent pregnancies developed recurrent PPCM, all of whom recovered. Migraine and anxiety were identified as novel possible risk factors for PPCM.

Conclusions:

The population-based incidence of PPCM was 20.3 cases per 100,000 live births in Olmsted County, Minnesota. Cardiovascular outcomes were generally excellent in this community cohort.

Left ventricular mass and myocardial scarring in women with hypertensive disorders of pregnancy

Aims

Hypertensive disorders of pregnancy (HDP) predict future cardiovascular events. We aim to investigate relations between HDP history and subsequent hypertension (HTN), myocardial structure and function, and late gadolinium enhancement (LGE) scar.

Methods and results

We evaluated a prospective cohort of women with suspected ischaemia with no obstructive coronary artery disease (INOCA) who underwent stress/rest cardiac magnetic resonance imaging (cMRI) with LGE in the Women’s Ischemia Syndrome Evaluation-Coronary Vascular Dysfunction study. Self-reported history of pregnancy and HDP (gestational HTN, pre-eclampsia, toxaemia and eclampsia) were collected at enrollment. In our cohort of 346, 20% of women report a history of HDP. HDP history was associated with 3.2-fold increased odds of HTN. Women with a history of both HDP and HTN had higher cMRI measured left ventricular (LV) mass compared with women with HDP only (99.4±2.6 g vs 87.7±3.2 g, p=0.02). While we found a similar frequency of LGE scar, we observed a trend towards increased LGE scar size (5.1±3.4 g vs 8.0±3.4 g, p=0.09) among the women with HDP history compared to women without.

Conclusion

In a high-risk cohort of women with suspected INOCA, 20% had a history of HDP. Women with HDP history were more likely to develop HTN. Our study demonstrates higher LV mass in women with HDP and concomitant HTN. Although the presence of LGE scar was not different in women with and without HDP history, we observed a trend towards larger scar size in women with HDP. Future studies are needed to better assess the relationship of HDP and cardiac morphology and LGE scarring in a larger cohort of women.

Increased arterial stiffness and reduced left ventricular long-axis function in patients recovered from peripartum cardiomyopathy

Background

Peripartum cardiomyopathy (PPCM) is idiopathic pregnancy‐associated heart failure (HF) with reduced left ventricular ejection fraction (LVEF). We aimed to assess arterial stiffness and left ventricular (LV) function in women recovered from PPCM compared with controls.

Methods

Twenty‐two PPCM patients were compared with 15 age‐matched controls with previous uncomplicated pregnancies. Eleven of the patients were at inclusion in the study recovered and off medication since at least 6 months and still free from cardiovascular symptoms with normal LVEF and normal NT‐proBNP. All underwent echocardiography, including LV strain, left atrial (LA) reservoir strain and tissue Doppler early diastolic velocity (e´) and non‐invasive assessment for arterial stiffness and central aortic systolic blood pressure (AoBP) at rest and immediately postexercise.

Results

The patients off medication showed alterations compared with controls. AoBP was higher (120 ± 9 mm Hg vs. 104 ± 13 mm Hg; p = .001), a difference which persisted postexercise. The arterial elastance was higher (1.9 ± 0.4 mm Hg/ml vs. 1.3 ± 0.2 mm Hg/ml; p < .001), while there were lower e´ septal (8.9 ± 1.7 cm/s vs. 11.0 ± 1.1 cm/s; p = 0. 002), LV global strain (18.7 ± 3.9% vs. 23.1 ± 1.6%; p = .004) and LA reservoir strain (24.8 ± 9.1% vs. 37.7 ± 6.3%; p = .002).

Conclusions

Compared with healthy controls, PPCM patients considered recovered and off medication had increased arterial stiffness, decreased LV longitudinal function and reduced LA function.

Cardiovascular effects of severe late-onset preeclampsia are reversed within six months postpartum

OBJECTIVES

Preeclampsia (PE) is a common pregnancy-related disorder associated with cardiovascular long-term disease. Eighty percent are late-onset PE, occurring after 34 gestational weeks, and can present with severe symptoms. Magnitude and reversibility rate of maternal cardiovascular changes after severe late-onset PE have not been characterized. This study therefore evaluated longitudinal dynamics of maternal cardiovascular changes after severe late-onset PE.

STUDY DESIGN

Six previously normotensive women with severe late-onset PE and eight pregnant controls were included. Severe PE was defined as systolic blood pressure (SBP) ≥ 160 mmHg or diastolic blood pressure (DBP) ≥ 110 mmHg and proteinuria with/without evidence of end-organ dysfunction, or SBP ≥ 140 mmHg or DBP ≥ 90 mmHg with/without proteinuria and with evidence of end-organ dysfunction. Cardiovascular function was assessed by magnetic resonance imaging at 1-3 days, one week and six months postpartum.

RESULTS

Left ventricular mass at 1-3 days postpartum was higher after severe late-onset PE (57 g/m²) compared to after normal pregnancy (48 g/m²; p = 0.01). Pulse wave velocity (PWV) decreased between 1 and 3 days and six months postpartum after PE (6.1 to 5.0 m/s; p = 0.028). There was no difference in PWV 1-3 days postpartum after severe PE compared after normal pregnancy (6.1 versus 5.6 m/s; p = 0.175). Blood pressure normalized within six months in all but one patient.

CONCLUSIONS

Cardiac effects after severe late-onset PE were small and transient. This indicates that left ventricular hypertrophy after severe late-onset PE may be a secondary physiologic response to increased peripheral resistance in PE. Vascular mechanisms rather than persistent cardiac hypertrophy postpartum may be the culprit for increased long-term cardiovascular risk after PE.

The Role of Multimodality Cardiovascular Imaging in Peripartum Cardiomyopathy

The burden of pregnancy-related heart disease has dramatically increased over the last decades due to the increasing age at first pregnancy and higher prevalence of cardiovascular risk factors such as diabetes, hypertension, and obesity. Pregnancy is associated with physiological changes in the cardiovascular system, including hemodynamic, metabolic, and hormonal adaptations to meet the increased metabolic demands of the mother and fetus. It has been postulated that pregnancy may act as a cardiovascular stress test to identify women at high risk for heart disease, where the inability to adequately adapt to the physiologic stress of pregnancy may reveal the presence of genetic susceptibility to cardiovascular disease or accelerate the phenotypic expression of both inherited and acquired heart diseases, such as peripartum cardiomyopathy (PPCM). PPCM is a rare and incompletely understood clinical condition. Despite recent advances in the understanding of its pathogenesis, PPCM is not attributable to a well-defined pathological mechanism, and therefore, its diagnosis still relies on the exclusion of overlapping dilated phenotypes. Cardiac imaging plays a key role in any peripartum woman with signs and symptoms of heart failure in establishing the diagnosis, ruling out life-threatening complications, guiding therapy and conveying prognostic information. Echocardiography represents the first-line imaging technique, given its robust diagnostic yield and its favorable cost-effectiveness. Cardiovascular magnetic resonance is a biologically safe high-throughput modality that allows accurate morpho-functional assessment of the cardiovascular system in addition to the unique asset of myocardial tissue characterization as a pivotal piece of information in the pathophysiological puzzle of PPCM. In this review, we will highlight current evidence on the role of multimodality imaging in the differential diagnosis, prognostic assessment, and understanding of the pathophysiological basis of PPCM.

Left ventricular function recovery in peripartum cardiomyopathy: a cardiovascular magnetic resonance study by myocardial T1 and T2 mapping

BACKGROUND

Peripartum cardiomyopathy (PPCM) is rare and potentially life-threatening; its etiology remains unclear. Imaging characteristics on cardiovascular magnetic resonance (CMR) and their prognostic significance have rarely been studied. We sought to determine CMR's prognostic value in PPCM by using T1 and T2 mapping techniques.

METHODS

Data from 21 PPCM patients from our CMR registry database were analyzed. The control group comprised 20 healthy age-matched females. All subjects underwent comprehensive contrast-enhanced CMR. T1 and T2 mapping using modified Look-Locker inversion recovery and T2 prep balanced steady-state free precession sequences, respectively. Ventricular size and function, late gadolinium enhancement (LGE), myocardial T1 value, extracellular volume (ECV), and T2 value were analyzed. Transthoracic echocardiography was performed at baseline and during follow-up. The recovered left ventricular ejection fraction (LVEF) was defined as LVEF ≥50% on echocardiography follow-up after at least 6 months of the diagnosis.

RESULTS

CMR imaging showed that the PPCM patients had severely impaired LVEF and right ventricular ejection fraction (LVEF: 26.8 ± 10.6%; RVEF: 33.9 ± 14.6%). LGE was seen in eight (38.1%) cases. PPCM patients had significantly higher native T1 and ECV (1345 ± 79 vs. 1212 ± 32 ms, P < 0.001; 33.9 ± 5.2% vs. 27.1 ± 3.1%, P < 0.001; respectively) and higher myocardial T2 value (42.3 ± 3.7 vs. 36.8 ± 2.3 ms, P < 0.001) than did the normal controls. After a median 2.5-year follow-up (range: 8 months-5 years), six patients required readmission for heart failure, two died, and 10 showed left ventricular function recovery. The LVEF-recovered group showed significantly lower ECV (30.7 ± 2.1% vs. 36.8 ± 5.6%, P = 0.005) and T2 (40.6 ± 3.0 vs. 43.9 ± 3.7 ms, P = 0.040) than the unrecovered group. Multivariable logistic regression analysis showed ECV (OR = 0.58 for per 1% increase, P = 0.032) was independently associated with left ventricular recovery in PPCM.

CONCLUSIONS

Compared to normal controls, PPCM patients showed significantly higher native T1, ECV, and T2. Native T1, ECV, and T2 were associated with LVEF recovery in PPCM. Furthermore, ECV could independently predict left ventricular function recovery in PPCM.

Hypertensive Disorders of Pregnancy and Future Maternal Health: How Can the Evidence Guide Postpartum Management?

PURPOSE OF REVIEW

To review the postpartum management of hypertensive disorders of pregnancy.

RECENT FINDINGS

Hypertensive disorders are associated with an increased risk of future cardiovascular disease; however, there is a poor understanding of the underlying mechanisms and few recommendations to guide care in the postpartum period. Recent studies have shown high rates of masked hypertension and home blood pressure monitoring in the first year postpartum may be a promising opportunity to monitor health given evidence of high maternal adherence to this approach. In longer term, women with a history of a hypertensive disorder of pregnancy have higher blood pressures, increased risk of metabolic syndrome, and perhaps excess diastolic dysfunction. Triaging risk and improving handoff from the obstetrician to the primary care provider or subspecialist should be a priority in this population. Hypertensive disorders of pregnancy remain an untapped opportunity to identify excess cardiovascular risk in affected women at a time when mitigating that risk during the reproductive years has the potential to improve future pregnancy health as well as improve women's long-term cardiometabolic health.

Long-Term Cardiac Function After Peripartum Cardiomyopathy and Preeclampsia: A Danish Nationwide, Clinical Follow-Up Study Using Maximal Exercise Testing and Cardiac Magnetic Resonance Imaging

Background Long-term clinical studies of peripartum cardiomyopathy ( PPCM ) are few. We aimed to measure the long-term effect of PPCM on cardiac function in comparison with the long-term effects of severe preeclampsia and uncomplicated pregnancy. Methods and Results A nationwide Danish cohort of women diagnosed with PPCM from 2005 to 2014 ( PPCM group) were invited to participate in a clinical follow-up study including maximal cardiopulmonary exercise testing and cardiac magnetic resonance imaging. Matched women with previous severe preeclampsia (preeclampsia group) and previous uncomplicated pregnancies (uncomplicated pregnancies group) served as comparison groups. A total of 84 women with 28 in each group participated. Median time to follow-up after PPCM was 91 months. Most women (85%) in the PPCM group reported no symptoms of heart failure. Mean left ventricular ejection fraction in the PPCM group was normal at 62%, but significantly lower than in the preeclampsia group and the uncomplicated pregnancies group where mean left ventricular ejection fraction was 69% and 67%, respectively ( P<0.0001). Women in the PPCM group also had impaired diastolic function with reduced left ventricular peak filling rate, left atrial passive emptying volume, and left atrial passive emptying fraction. Maximal exercise capacity (peak VO ₂) was also reduced in the PPCM group compared with the preeclampsia group and the uncomplicated pregnancies group, and PPCM , high body mass index, and low left ventricular ejection fraction independently predicted reduced peak VO ₂. Only 1 woman with PPCM had late gadolinium enhancement. Conclusions Women generally recovered left ventricular ejection fraction and were asymptomatic 7 years after PPCM , but had subtle diastolic dysfunction on cardiac magnetic resonance imaging and reduced peak VO ₂. Focal myocardial fibrosis assessed with late gadolinium enhancement was, however, uncommon.