Peripartum Cardiomyopathy Review: Key Points
The following are key points to remember from a review of peripartum cardiomyopathy (PPCM):
- PPCM is maternal heart failure with systolic dysfunction (left ventricular ejection fraction [LVEF] <45%) that develops in the last month of pregnancy or the first 5 months postpartum, but may also occur outside of this window.
- PPCM is a diagnosis of exclusion and should be differentiated from pre-existing cardiac disease (i.e., known cardiomyopathy, valvular disease, chemotherapy-induced cardiomyopathy, myocarditis, etc.).
- Worldwide, PPCM complicates approximately 1 in 2,000 live births. PPCM is more common in women with hypertensive disorders, especially pre-eclampsia.
- Racial disparities are significant. In the United States, Black women are four times more likely to develop PPCM, take twice as long to recover, and are twice as likely to have persistently impaired heart function.
- The pathogenesis of PPCM is likely triggered by a combination of vascular and hormonal insults that occur in late pregnancy, causing cardiac dysfunction in those with genetic or other predisposition.
- Approximately 15% of patients with PPCM have genetic variants similar to those identified in nonischemic dilated cardiomyopathy. Genetic testing should be considered in most cases of PPCM.
- Management involves guideline-directed medical treatment for heart failure with reduced EF. During pregnancy, beta-blockers, hydralazine plus isosorbide dinitrate, and diuretics can be used safely. With breast-feeding, most standard medications are acceptable; however, safety information is not yet available for sacubitril-valsartan and sodium-glucose contransporter 2 inhibitors.
- Additional treatment with bromocriptine, which inhibits prolactin release, is being actively investigated in the REBIRTH (Randomized Evaluation of Bromocriptine in Myocardial Recovery Therapy) trial (ClinicalTrials.gov; NCT05180773).
- Due to the peripartum hypercoagulable state, a low threshold for initiating anticoagulation is recommended, such as EF <30-35% or the presence of atrial fibrillation.
- Early after diagnosis, a temporary wearable defibrillator is preferred over an implantable cardioverter-defibrillator since cardiac function may recover.
- Vaginal delivery is preferred and lactation is not contraindicated. Breast-feeding is recommended by the World Health Organization and the American Academy of Pediatrics.
- Counseling for subsequent pregnancies is challenging and should be done by an experienced team.
- More data are needed regarding long-term outcomes and the safety of weaning cardiac medications after recovery of systolic function. Mechanistic research using murine models is limited by significant differences in placental function in humans versus mice.
- 14.Future work to address and resolve racial disparities in maternal health and PPCM is vitally important.
