Clinical Characteristics of Peripartum Cardiomyopathy in the United States: Diagnosis, Prognosis, and Management

Perspective:

The following are 10 points to remember regarding this recent review of peripartum cardiomyopathy:

1. The incidence of peripartum cardiomyopathy appears to be increasing, and is estimated to be approximately 1 in 3,200 American women.

2. Associations with peripartum cardiomyopathy include advanced maternal age, African American race, maternal hypertension, and multiple gestation.

3. Diagnosis of peripartum cardiomyopathy may be delayed because symptoms of dyspnea and orthopnea may commonly occur in normal pregnancy. While B-type natriuretic peptide (BNP) levels do not increase in normal pregnancy, they can be markedly elevated in peripartum cardiomyopathy.

4. Normalization of left ventricular (LV) function occurs in >50% of women with peripartum cardiomyopathy, and generally occurs within 2-6 months of diagnosis.

5. Predictors of LV recovery include LV diastolic dimension of <5.5 to 6 cm, LV ejection fraction >30%-35%, lack of troponin elevation, lower level of plasma BNP, absence of LV thrombus, breastfeeding, diagnosis after delivery, and non-African American race.

6. Subsequent pregnancies in women with peripartum cardiomyopathy are associated with increased risk for recurrent cardiomyopathy, persistent ventricular dysfunction, and mortality. The risk of recurrence is highest if cardiac dysfunction is persistent at the time of subsequent pregnancies. Recurrence of peripartum cardiomyopathy may occur despite recovery of LV function.

7. Given the known benefits of breastfeeding, the higher rate of recovery of LV function in breastfeeding mothers, and the relative compatibility of most heart failure drugs with breastfeeding, women with peripartum cardiomyopathy should not be discouraged from breastfeeding.

8. In general, the treatment of heart failure in women with peripartum cardiomyopathy should be consistent with current guidelines for the treatment of heart failure in adults. Drug therapy may need to be altered during pregnancy or lactation to avoid detrimental effects to the fetus.

9. Anticoagulation should be continued until the LV ejection fraction is greater than 35%, and is particularly important in the first 6-8 weeks following delivery. Heparin products do not cross the placenta and may be used during pregnancy, and both warfarin and heparin are compatible with breastfeeding.

10. Multiple experimental drugs are under consideration and testing for peripartum cardiomyopathy. These include intravenous immune globulin, pentoxifylline, and bromocriptine.

Clinical Topics: Congenital Heart Disease and Pediatric Cardiology, Heart Failure and Cardiomyopathies, Prevention, CHD and Pediatrics and Prevention, Acute Heart Failure, Hypertension

Keywords: Ventricular Dysfunction, Ventricular Function, Left, Lactation, Placenta, Dyspnea, Peripartum Period, Prognosis, Immunoglobulins, Intravenous, Thrombosis, Pharmaceutical Preparations, Cardiomyopathies, Heart Failure, Fetus, Mothers, Breast Feeding, Diastole, Hypertension, United States, Pregnancy


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