Perspective:

This study from the PEACE Registry in Nigeria represents the largest study of PPCM in Africa. The higher mortality and lower recovery in this cohort, as compared with reports from the United States and Germany, are likely related to suboptimal treatment with heart failure medication and delays in diagnosis. Patients in this registry had low rates of beta-blocker and angiotensin-converting enzyme inhibitor/angiotensin-receptor blocker use, especially at the time of initial enrollment, but improvement in myocardial function was associated with beta-blocker use after 6 months. Inclusion criteria required women to have developed heart failure symptoms within 5 months of delivery; however, only 46 (19%) were enrolled in the study within that time frame, as the median enrollment was at 7 months postpartum (interquartile range, 5-10 months). In contrast, the majority of women in the United States and Germany are diagnosed within the first month after delivery. Late diagnosis is more likely to occur in women with ongoing symptoms of heart failure and persistent myocardial dysfunction. Patients in Nigeria with rapid recovery are less likely to have received subspecialty care and less likely to be represented in this registry. Therefore, this cohort represents women with persistent myocardial dysfunction after surviving the first 3-6 months. Predictors of mortality included hypotension, tachycardia, and LVEF <25% at diagnosis, consistent with findings of advanced heart failure. The strong association of beta-blocker use with improved survival and higher EF at 6 months suggests clear benefit. Timely diagnosis and treatment are important themes in all populations. Providing care in a resource-limited setting presents additional challenges.