Peripartum Cardiomyopathy - Summary
1. Definition
• Towards the end of pregnancy to 5 months postpartum
• Usually LVEF <45% with or without LV dilation
• Idiopathic LV dysfunction → exclude other causes*
2. Differential Diagnosis
• Pre-existing cardiomyopathy (e.g., familial or dilated)
• Valvular heart disease
• Congenital heart disease
• Hypertensive heart disease
• Myocardial infarction
• Stress cardiomyopathy
• Pulmonary embolus
3. Etiology
• Actual etiology remains unknown
• Final pathway likely an imbalance of angiogenic factors + oxidative stress
- Proposed Mechanism: Dysregulation of VEGF (Pro-Angiogenic) through ↑ sFLT1 levels (levels ↑ in pre-eclampsia)
- Proposed Mechanism: Altered prolactin processing with ↑ cleavage into a pro-angiogenic fragment
• Other: Myocarditis? Genetic predisposition (TTN gene) ? Hemodynamic stressors of pregnancy
4. Risk Factors and Worse Prognostic Markers
• Risk Factors: African ancestry, pre-eclampsia, hypertension, multiple pregnancy, maternal age > 30 years, cocaine use
• Worse Prognosis: LVEF < 30%, LVEDd > 6.0 cm, LV thrombus, RV systolic dysfunction, Obesity, African ancestry, LGE on MRI
5. Clinical
• Under-recognized: sx overlap with normal pregnancy
• May have typical HF sx: dyspnea on exertion, orthopnea, PND, LE edema
• Minority of Pts: cardiogenic shock and severe arrhythmias
6. Management during Pregnancy
• Avoid ARB/ACE-I/ARNI/MRA
• Avoid Warfarin and DOAC
• Planning for delivery mode and timing with Cardio-OB team
7. Management during Delivery
• Stable patients typically deliver vaginally
• Account for changes in hemodynamics (e.g., placental auto-transfusion and relief of IVC compression ↑ preload)
• A multi-disciplinary team is critical!
8. Management during Postpartum Period
• Breast-feeding: no consensus on risk vs. benefit. - Some studies show no ↓ LV function. Avoid ARBs
• ICD: Many patients will recover LVEF. Consider waiting ~6 months before 1° prevention. Possible role for wearable defibrillator as a "bridge to recovery"
• Contraception counseling should be done on diagnosis or discharge. Avoid estrogen products early post-partum
9. Other Considerations
• Thromboembolic complications are relatively common. In patients with LVEF (ESC), suggest prophylactic anticoagulation up to 8 weeks postpartum
• Consider early mechanical support for patients clinically deteriorating on medical therapy, including inotropes
• Bromocriptine, a dopamine agonist, prevents the release of prolactin. It is an investigative therapy in PPCM. If started, patients should be on a/c.
• If no LVEF recovery (e.g., <50%), ESC guidelines recommend against future pregnancy. Risk of recurrence remains even if recovery.
• During a future pregnancy, teratogenic GDMT meds (e.g., ACE/ARB) need to be stopped. Serial TTE and close follow-up with Cardio-OB team needed!
- Cardionerds - Karan Desai MD, MPH @karanpdesai
#Peripartum #Cardiomyopathy #diagnosis #management #cardiology #treatment
