Peripartum cardiomyopathy: current state of knowledge, new developments and future directions

Peripartum cardiomyopathy unveiled: Etiology, diagnosis, and therapeutic insights

Peripartum cardiomyopathy (PPCM) remains a significant challenge in maternal health, marked by its unpredictable onset and varied clinical outcomes. With rising incidence rates globally, understanding PPCM is vital for improving maternal care and prognosis. This review aims to consolidate current knowledge on PPCM, highlighting recent advancements in its diagnosis, management, and therapeutic approaches. This comprehensive review delves into the epidemiology of PPCM, underscoring its global impact and demographic variations. We explore the complex etiology of the condition, examining known risk factors and discussing the potential pathophysiological mechanisms, including oxidative stress and hormonal influences. The clinical presentation of PPCM, often similar yet distinct from other forms of cardiomyopathy, is analyzed to aid in differential diagnosis. Diagnostic challenges are addressed, emphasizing the role of advanced imaging and biomarkers. Current management strategies are reviewed, focusing on the absence of disease-specific treatments and the application of general heart failure protocols. The review also discusses the prognosis of PPCM, factors influencing recovery, and the implications for future pregnancies. Finally, we highlight emerging research directions and the urgent need for disease-specific therapies, aiming to provide a roadmap for future studies and improved patient care. This review serves as a crucial resource for clinicians and researchers, contributing to a deeper understanding and better management of PPCM.

Inflammatory Markers Predicting Pathological Complete Response in Cases with Breast Cancer Treated by Neoadjuvant Chemotherapy

Objective

Response to neoadjuvant chemotherapy (NAC) is predictive for survival times in some patients with breast cancer (BC). The aim of this study is to explore the predictive value of some inflammatory markers including neutrophil-to-lymphocyte ratio (NLR), derived neutrophil-to-lymphocyte ratio (dNLR), monocyte-to-high density lipoprotein ratio (MHR) and prognostic nutritional index (PNI) in cases with BC treated with NAC.

Materials and Methods

One hundred and ten patients with BC treated with NAC were included in the study. Measurements for NLR, dNLR, MHR and PNI were calculated with available formulas. The value of NLR, dNLR, MHR and PNI in predicting pCR to NAC in BC was analyzed using receiver operating characteristic (ROC) curve analysis. All analyses were performed using the SPSS statistical software package (SPSS statistics 21.0).

Results

Mean NLR values were 2.2±0.8 vs. 2.6±1.3 for pCR (+) and pCR (-) groups (p=0.603). Mean dNLR values were 1.5±0.5 vs. 1.9±0.8 for pCR (+) and pCR (-) groups, respectively and this was statistically significant (p=0.022). Mean MHR values were 15.4±17.2 vs. 13.2±10.1 for pCR (+) and pCR (-) groups (p=0.406). Mean PNI values were 52±5.1 vs. 49±5.8 for pCR (+) and pCR (-) groups, and this was statistically significant (p=0.015). In multiple logistic regression analysis PNI was found to be independent factor for pCR.

Conclusion

In this study pre-treatment dNLR and PNI were found to be predictive for pCR while NLR and MHR were not found to be associated with pCR. PNI and dNLR are simple but useful biomarkers predicting response to NAC.

Prognostic nutritional index as a novel marker for prediction of prognosis in patients with peripartum cardiomyopathy

The clinical significance of poor nutritional status in patients with peripartum cardiomyopathy (PPCM) is not clearly understood. Prognostic nutritional index (PNI) is a simple nutritional assessment tool, which was first demonstrated to be valuable in patients with colorectal surgeries. We aimed to investigate the predictive value of PNI in patients with PPCM.A total of 92 patients diagnosed with PPCM were enrolled in this study. PNI was calculated using the following formula: 10 × serum albumin value (g/dL) + 0.005 × total lymphocyte count. The primary endpoint was defined as composite adverse cardiac events that included cardiac death or hospitalization due to worsening heart failure (HF). Cardiac death, hospitalization due to worsening HF, and persistent left ventricular (LV) systolic dysfunction were evaluated, respectively, as secondary endpoints.Primary composite endpoint was higher in the lower PNI group. After adjusting for other risk factors, PNI was found to be as an independent predictor of primary composite endpoint (odds ratio 0.805; 95% confidence interval 0.729-0.888; P < .001). In addition, PNI was significantly associated with secondary endpoints; persistent LV systolic dysfunction as well as cardiac death.This study identified nutritional status assessed by the PNI seems to be a novel predictor of adverse cardiovascular outcomes in patients with PPCM.

Comparison of monocyte with high density lipoprotein cholesterol ratio in dipper and nondipper hypertensive patients

Aim: We aimed to compare the monocyte to HDL-cholesterol ratio (MHR) of nondipper hypertension (NDHT) and dipper hypertension patients. Patients & methods: A total of 162 patients were included in the study. Patients were grouped as dipper and nondipper according to 24-h ambulatory blood pressure recordings. Results: The MHR was significantly higher in nondipper hypertension group compared with control (p < 0.001) and dipper hypertension groups (p = 0.03). MHR, hs-CRP and red-cell distribution width (RDW) were independent predictors of nondipper hypertension. Area under the curve was 0.62 (p = 0.034) for MHR and 0.61 (p = 0.012) for hs-CRP in the ROC analysis. Conclusion: MHR has elevated levels in NDHT patients. Increased levels of MHR may evaluate as increased risk of cardiovascular events in NDHT patients.

Fragmented QRS as a candidate marker for left ventricular nonrecovery in patients with peripartum cardiomyopathy

BACKGROUND

Fragmented QRS (fQRS) complex, with various morphology, has been recently described as a diagnostic criterion of several cardiac diseases. However, there are little data regarding the prognostic role of fQRS in peripartum cardiomyopathy (PPCM) patients. We aimed to investigate the effect of fQRS on predicting left ventricular (LV) nonrecovery in patients with peripartum cardiomyopathy (PPCM).

METHODS

Ninety patients (mean age: 34.7 ± 6.5 years) with the diagnosis of PPCM were analyzed retrospectively. The median follow-up period of was 67.0 (12.0-192.0) months. Fragmented QRS was defined as the presence of various RSR' patterns (QRS duration < 120 ms) with or without Q wave, which include an additional R wave (R' prime) or notching of the R wave or S wave, or the presence of more than one R' (fragmentation) without typical bundle branch block. Recovery of LV function was defined as the presence of LV ejection fraction (EF) >45%.

RESULTS

Of the patients, 54 (60%) did not recover LV function at the last follow-up visit (nonrecovery group), while 36 of the patients (40%) exhibited LV recovery (recovery group). LV ejection fraction (EF) and fQRS were identified as independent predictors of LV nonrecovery in patients with PPCM (odds ratio OR: 5.546, 95% confidence interval CI: 0.792-0.979, p = .019 and OR: 5.986, 95% CI: 1.313-11.787, p = .014, respectively).

CONCLUSION

Our data firstly indicated that presence of fQRS was a significant predictor of LV nonrecovery in patients with PPCM. The fQRS might assist in identifying high-risk patients.

An Unusual Case of Shock Following an Elective Caesarean Delivery

BACKGROUND

The differential diagnosis of peripartum chest pain and cardiogenic shock is broad and includes pulmonary embolism, amniotic fluid embolism, peripartum and Takotsubo cardiomyopathy, myocardial infarction, and anaesthetic complications.

CASE

A 31-year-old woman with Addison's disease underwent an elective caesarean section that was complicated by chest pain and cardiogenic shock. After initial resuscitation, she was transferred to a tertiary hospital, and urgent transthoracic echocardiography revealed severe systolic dysfunction. She was treated with an increased dose of hydrocortisone and intravenous furosemide and improved. Follow-up imaging showed improvement of left ventricular systolic function.

CONCLUSION

In patients with cardiogenic shock after delivery, early transthoracic echocardiography is a non-invasive tool that can rapidly narrow the differential diagnosis.

A novel marker of persistent left ventricular systolic dysfunction in patients with peripartum cardiomyopathy: monocyte count- to- HDL cholesterol ratio

Background

Peripartum cardiomyopathy (PPCM) is a rare but potentially life-threatening complication of pregnancy. There is limited data regarding the predictors of persistent left ventricular (LV) systolic dysfunction. Recently, monocyte-to-high density lipoprotein (HDL) cholesterol ratio (MHR) has emerged as a novel indicator of inflammation and oxidative stress. We aimed to assess the predictive value of MHR on LV recovery in patients with PPCM.

Methods

A total of 64 patients with PPCM who admitted to our tertiary reference hospital between 2009 and 2017 were retrospectively analyzed in this study. Demographic and clinical data, laboratory parameters and echocardiographic findings were recorded. The duration of follow-up was at least 12 months after diagnosis for all participants. Recovery of LV systolic function was defined as the presence of LV ejection fraction (LV EF) > 45%. Univariate analysis was used to determine the significant predictors of persistent LV systolic dysfunction (non-recovery). A receiver operating characteristic (ROC) curve was used to establish the cut-off values for predictors.

Results

The mean follow-up duration was 72.1 ± 5.5 months. Of the 64 patients, 35 (55%) had persistent LVSD at their last follow-up while 29 (45%) showed LV EF improvement. The baseline MHR levels were significantly higher in the non-recovery group (P < 0.001). In univariate analysis, increased MHR levels (odds ratio:1.17; 95% confidence interval, 1.01–1.35; P < 0.001) significantly predicted LV non-recovery. Using a cut-off level of 9.73, MHR predicted persistent LV systolic dysfunction with a sensitivity of 89% and specificity of 79%. Besides, lower baseline LVEF increased WBC and CRP levels were identified as predictors of LV non-recovery.

Conclusions

Our data firstly indicated that elevated MHR was a significant predictor of persistent LV systolic dysfunction in PPCM. The MHR might contribute to determining high-risk patients with PPCM.

The prognostic value of positive T wave in lead aVR: A novel marker of adverse cardiac outcomes in peripartum cardiomyopathy

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.

Anesthetic Treatment of Cardiac Disease During Pregnancy

PURPOSE OF REVIEW

This review summarizes the pathophysiology, peripartum treatment, and anesthetic management of parturients with cardiac disease. Valvular disease, coronary disease, and cardiomyopathy are specifically addressed in the context of the normal physiologic changes of pregnancy. We offer recommendations for anesthetic approaches, hemodynamic goals with an emphasis on interdisciplinary planning between anesthesiologists, cardiologists, cardiothoracic surgeons, obstetricians, maternal fetal medicine specialists, and neonatologists.

RECENT FINDINGS

Vaginal delivery with neuraxial analgesia can be well tolerated by many pregnant patients with cardiac disease when coordinated by an interdisciplinary team of experts. Cardiac disease in pregnancy can present a significant challenge for the interdisciplinary care team. A detailed understanding of each patient's cardiac pathology and the physiologic changes of pregnancy are critical to ensure a safe and successful labor and delivery. Optimized medical therapy in the peripartum period and neuraxial anesthesia with the judicious use of vasoactive agents can be of great benefit for these parturients. As is generally the case, cesarean delivery should be primarily reserved for obstetric indications and maternal wellbeing, with careful consideration of the fetus to guide best practices.

Clinical outcomes of peripartum cardiomyopathy: a 15-year nationwide population-based study in Asia

Peripartum cardiomyopathy (PPCM) is the development of heart failure during late pregnancy to months postpartum with potential fatal outcome. However, the disease is not well-studied in Asia.We aimed to investigate the epidemiology and clinical outcomes of PPCM in Taiwan.Electronic medical records were retrieved from Taiwan National Health Insurance Research Database from 1997 to 2011. Patients with PPCM were separated into 3 groups based on the timing of diagnosis. Early: PPCM diagnosed first to ninth month of pregnancy. Traditional: PPCM diagnosed last month of pregnancy till fifth month post-delivery. Late: PPCM diagnosed sixth to twelfth month post-delivery. Primary outcomes defined as cardiac death, all-cause mortality, and major adverse cardiovascular events (MACE) within 1 year.A total of 3,506,081 deliveries during 1997 to 2011 were retrieved and 925 patients with PPCM were identified. Overall incidence of PPCM was 1:3,790 during the 15 years. Early, Traditional, and Late group each had 88, 742, and 95 patients. Cardiac death occurred in 31 patients, all-cause mortality in 72 patients, and MACE in 65 patients. Late group had 2- to 3-fold event rates in cardiac death, all-cause mortality, and MACE compared with Early and Traditional groups. Cumulative incidence showed significant differences for cardiac death (P = .0011), all-cause mortality (P = .0031), and MACE (P = .0014) among 3 groups. Multivariate Cox model showed Late group had significantly worse outcomes after adjusted for clinical variables compared with 2 other groups.Our study is the largest national cohort among Asian countries that showed timing of diagnosis of PPCM had different outcomes. Late diagnosis portended significantly increased morbidity and mortality, even after adjusted for clinical variables.

Peripartum Cardiomyopathy Treatment with Dopamine Agonist and Subsequent Pregnancy with a Satisfactory Outcome

Pathophysiological mechanisms of peripartum cardiomyopathy are not yet completely defined, although there is a strong association with various factors that are already known, including pre-eclampsia. Peripartum cardiomyopathy treatment follows the same recommendations as heart failure with systolic dysfunction. Clinical and experimental studies suggest that products of prolactin degradation can induce this cardiomyopathy. The pharmacological suppression of prolactin production by D2 dopamine receptor agonists bromocriptine and cabergoline has demonstrated satisfactory results in the therapeutic response to the treatment. Here we present a case of an adolescent patient in her first gestation with peripartum cardiomyopathy that evolved to the normalized left ventricular function after cabergoline administration, which was used as an adjuvant in cardiac dysfunction treatment. Subsequently, despite a short interval between pregnancies, the patient exhibited satisfactory progress throughout the entire gestation or puerperium in a new pregnancy without any cardiac alterations. Dopamine agonists that are orally used and are affordable in most tertiary centers, particularly in developing countries, should be considered when treating peripartum cardiomyopathy cases.