Perspective:

This is a large multinational observational registry of over 700 women with PPCM from 49 countries in Europe, Africa, Asia-Pacific, and the Middle East. Several important points about PPCM are illustrated in this study:

1. Significant morbidity and mortality can result from PPCM and early detection is important. At 6 months, the mean mortality rate was 6%, and just under half of the deaths occurred within the first 30 days of diagnosis. Less than half had recovery of LVEF to 50% or higher, and many had persistent dysfunction.
2. The majority of deaths were sudden or related to heart failure. More research is needed to determine which patients are at highest risk of arrhythmias, potentially benefiting from wearable cardioverter defibrillators or early ICD placement.
3. Adverse outcomes may be more prevalent than reflected in this registry. Nearly 20% of the initial cohort did not have follow-up at 6 months, women with severe illness may have died prior to enrollment or during follow-up, and participating sites that focus on PPCM may have better outcomes than sites where this diagnosis might initially be missed. Follow-up longer than 6 months would also be informative.
4. Thromboembolic events occurred in 7% (including deep vein thrombosis, pulmonary embolism, arterial embolism, and ischemic stroke). Fewer than one sixth of the women in the registry were anticoagulated in the 6 months after discharge. Anticoagulation for PPCM is indicated for LV thrombus, and recommended for atrial fibrillation and/or severe LV dysfunction, but additional research is needed to better identify which patients should be anticoagulated. Other factors that could contribute to thromboembolic risk (i.e., deep vein thrombosis and pulmonary embolism) include immobilization due to severe heart failure or cesarean delivery.
5. Other studies have observed that delays in diagnosis of PPCM are common, which may be related in part to the overlap of symptoms of heart failure with those of normal pregnancy. This study, however, found that fewer than two thirds of patients had pulmonary rales or peripheral edema, suggesting that the physical exam findings of pregnancy-associated heart failure may not be sensitive. In addition, one quarter of women with mild symptoms actually had severe LV dysfunction. Thus, a high index of suspicion is necessary and additional testing with B-type natriuretic peptide (BNP)/pro-BNP levels and an echocardiogram may be indicated.