Clinical Outcomes for Peripartum Cardiomyopathy in North America

Abstract

BACKGROUND Peripartum cardiomyopathy (PPCM) remains a major cause of maternal morbidity and mortality. OBJECTIVES This study sought to prospectively evaluate recovery of the left ventricular ejection fraction (LVEF) and clinical outcomes in the multicenter IPAC (Investigations of Pregnancy Associated Cardiomyopathy) study. METHODS We enrolled and followed 100 women with PPCM through 1 year post-partum. The LVEF was assessed by echocardiography at baseline and at 2, 6, and 12 months post-partum. Survival free from major cardiovascular events (death, transplantation, or left ventricular [LV] assist device) was determined. Predictors of outcome, particularly race, parameters of LV dysfunction (LVEF), and remodeling (left ventricular end-diastolic diameter [LVEDD]) at presentation, were assessed by univariate and multivariate analyses. RESULTS The cohort was 30% black, 65% white, 5% other; the mean patient age was 30 ± 6 years; and 88% were receiving beta-blockers and 81% angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. The LVEF at study entry was 0.35 ± 0.10, 0.51 ± 0.11 at 6 months, and 0.53 ± 0.10 at 12 months. By 1 year, 13% had experienced major events or had persistent severe cardiomyopathy with an LVEF <0.35, and 72% achieved an LVEF ≥0.50. An initial LVEF <0.30 (p = 0.001), an LVEDD ≥6.0 cm (p < 0.001), black race (p = 0.001), and presentation after 6 weeks postpartum (p = 0.02) were associated with a lower LVEF at 12 months. No subjects with both a baseline LVEF <0.30 and an LVEDD ≥6.0 cm recovered by 1 year post-partum, whereas 91% with both a baseline LVEF ≥0.30 and an LVEDD <6.0 cm recovered (p < 0.00001). CONCLUSIONS In a prospective cohort with PPCM, most women recovered; however, 13% had major events or persistent severe cardiomyopathy. Black women had more LV dysfunction at presentation and at 6 and 12 months post-partum. Severe LV dysfunction and greater remodeling at study entry were associated with less recovery. (Investigations of Pregnancy Associated Cardiomyopathy [IPAC]; NCT01085955)

Myocardial Damage Detected by Late Gadolinium Enhancement Cardiac Magnetic Resonance Is Uncommon in Peripartum Cardiomyopathy

“…The origins of the discrepancy in LGE prevalence between our study and the study by Haghikia and colleagues remain uncertain. Yet, the low prevalence of LGE reported in our work is concordant with the observed improvement in systolic function shown by echocardiographic results from the parent study 1. Since LGE indicates irreversible focal myocardial damage, even when ejection fraction is preserved,8, 9, 10 the overall low prevalence of LGE in this study represents an optimistic finding.…”

“…The Investigations of Pregnancy Associated Cardiomyopathy (IPAC) cohort has been described previously 1. Briefly, among 100 women from 30 centers enrolled within the IPAC study, we recruited a subset of 40 women who provided written and oral informed consent after institutional review board approval to undergo CMR scans with Gd contrast to permit LGE imaging.…”

“…This knowledge is important to inform mechanisms of disease in PPCM, a clinical condition that manifests a broad spectrum of severity 1. The overall favorable prognosis of PPCM where most women recover systolic function and fare well2 suggests a low prevalence of LGE.…”

Peripartum Cardiomyopathy

“…This study found that 71% of the women recovered LVEF to >50%, whereas only 13% had major events or persistent cardiomyopathy with EF <35%. 80 Recovery occurred almost uniformly by 6 months, with little change in EF thereafter, as has been noted by previous studies. 11,81 Recovery of LVEF after 6 months can sometimes occur, however, and should not be ruled out.…”

Peripartum cardiomyopathy, what if your patient plans to reconceive?

“…These factors are diverse from being clinical, hormonal, or imaging modalities. Some examples include race, comorbidities, relaxin level, pro‐BNP titer, LV dimension in diastole, and global longitudinal strain 1, 2, 3, 4, 5. A consensus on how to estimate the risk of PPCM relapse is lacking.…”