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Long-Term Outcomes of Pregnancy After Peripartum Cardiomyopathy
Quick Takes
- Even after recovery of cardiac function, a subsequent pregnancy can carry risk of adverse outcomes.
- Risk factors that could explain the high risk of adverse outcomes in this study include low socioeconomic status, racial disparities, delays in diagnosis, cocaine use, medication nonadherence, and health care inequities.
Study Questions:
What are the long-term outcomes among women with subsequent pregnancy (SSP) after peripartum cardiomyopathy (PPCM)?
Methods:
This was a retrospective chart review of 45 patients with SSP (1982–2020) after a diagnosis of PPCM at a single institution in Louisiana. Myocardial recovery was defined as left ventricular ejection fraction (LVEF) ≥50%. Adverse outcomes were defined as symptomatic heart failure, cardiogenic shock, thromboembolic event, implantable cardioverter-defibrillator placement, left ventricular assist device (LVAD) placement, cardiac transplant, mortality, or relapse of PPCM (defined as a drop in LVEF by 10%, or to <45% if LVEF was ≥50% prior to pregnancy).
Results:
Of 45 women with 78 SSPs, 80% were of African American descent and 76% were from low socioeconomic background. Thirty (67%) women were in the recovery group (RG) (LVEF ≥50% prior to the SSP). During the first SSP, recurrent heart failure and relapse in LVEF were higher in the nonrecovery group (NRG) compared with the RG (33 vs. 3%, p = 0.01; 47 vs. 20%, p = 0.09, respectively). At median follow-up of 8 years, the rates of adverse maternal outcomes were 53% in the NRG versus 33% in the RG (p = 0.2). Total mortality at 8 years was 20% (n = 9). Six of these women were in the RG, with survival ranging from 3 months to 28 years after first SSP.
Conclusions:
Subsequent pregnancies after PPCM are associated with short- and long-term adverse events, even among women with initial LVEF recovery.
Perspective:
Many patients diagnosed with PPCM desire an additional pregnancy. Counseling about risk of relapse and long-term myocardial dysfunction are challenging aspects of preconception counseling due to limited studies. Patients with LVEF <50% are frequently advised to avoid pregnancy based on the high risk of adverse events; however, patients with “recovery” (defined in several PPCM studies as LVEF ≥50%) may be counseled about risks but frequently decide to proceed with another pregnancy, while maintaining close monitoring. Prior studies have reported a small risk of relapse with some having persistent cardiac dysfunction, but no maternal mortality. In this study, 6 of the 30 women in the recovered group died (20%). The high mortality rate in this study may be related to a variety of factors including racial disparities, inequities in health care, socioeconomic determinants of health, cocaine use, medication nonadherence, and the long duration of follow-up (the deaths occurred at 3 months, 7, 8, 15, 20, and 28 years following the first SSP). These results highlight the challenges in predicting risk and the importance of ongoing long-term follow-up, especially if weaning guideline-directed medications.
Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Cardiovascular Care Team, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, Implantable Devices, SCD/Ventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Acute Heart Failure, Heart Transplant, Mechanical Circulatory Support
Keywords: Cardiomyopathies, Cocaine, Counseling, Defibrillators, Implantable, Heart-Assist Devices, Heart Failure, Heart Transplantation, Medication Adherence, Peripartum Period, Pregnancy, Puerperal Disorders, Race Factors, Recurrence, Risk Factors, Secondary Prevention, Shock, Cardiogenic, Socioeconomic Factors, Thromboembolism, Ventricular Dysfunction, Women
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