Peripartum Cardiomyopathy

Question 1

Incidence in US

Answer 1

25-100 per 100,000 live births in US

Question 2

Define PPM CM

Answer 2

nonischemic cardiomyopathy/development of heart failure presenting late in pregnancy (last month) and first few months ppm (up to 5 months) in the absence of other known identifiable causes or prior heart disease

Weakness of the heart muscle with significant left ventricular dysfunction and heart failure with absence of other identifiable causes

decrease in LVEF < 45% and no previous h/o cardiac disease

Question 3

Etiology

Answer 3

Uncertain etiology. Possible autoimmune pathogenesis vs vascular or genetic etiology

Question 4

Risk factors

Answer 4

African American or Caribbean ancestry, AMA, multiple pregnancy, multiple hx, prolonged use of tocolytics, GHTN, preE, prior hx

Question 5

S/s

Answer 5

Of heart failure: sob, chest discomfort, palpitations, arrythmias or fluid retention

Question 6

Ddx

Answer 6

HTN, CAD, Valvular dx, cardiotoxic chemo or thoracic radiotherapy, Lupus, Thyrotoxicosis

Question 7

Diagnostic criteria

Answer 7

Echo (EF < 45%, impaired fractional shortening <30%, increased LVED dimension with an EDD (end diastolic dimension) > 2.7 cm/m2 of BSA)

FS is the percentage change in LV diameter during systole

Question 8

How would you evaluate?

Answer 8

CKMB, troponins, BNP, ABG, EKG/Echo, CXR and Cardiology Consult and Pregnancy Heart Team

Question 9

Therapeutic options

Answer 9

First line: Diuretics (HCTZ and Furosemide) to optimize/decrease preload and volume status

Fluid restriction

Digoxin – to increase contractility

Second line: Vasodilators-ACEi(Captopril, Enalapril), ARBs, (Hydralazine and Nitroglycerin drip if pregnant) afterload decrease

B-blockers: Metoprolol, Carvedilol and Bisoprolol, (labetalol and propranolol if pregnant) - to decrease myocardial oxygen demand

Hydralazine – decrease afterload

Pentoxifylline – inflammation reduction

Bromocriptine – decrease levels of 16 kDa fragment prolactin which may induce myocardial damage

Question 10

When should you anticoagulate?

Answer 10

if LV thrombus or A fib; or with significant LV dilation (EDV dimension >2.7 cm/m2 of BSA, EF <35%, atrial dysrhythmia); not if neither

Question 11

Lifestyle changes

Answer 11

low salt diet <4g/day; fluid restriction < 2L/day and activity limitation

Question 12

What to avoid

Maintenance of PaO2

Answer 12

Maintain PaO2 >/= 70 mmHg

Predicted outcome by severity of left ventricular dysfunction. Lower left VEF have poorer outcomes.

Avoid HTN, excessive fluid, and increase in cardiac demand

Question 13

Recovery by EF

Answer 13

EF > 30%, 90% complete myocardial recovery

 EF < 30%, less myocardial recovery and higher rates of left ventricular assist device implantation, cardiac transplantation and death 

    19% mortality risk, 44% for continued sxs of HF

Question 14

Death rate/cardiac complication rate

Answer 14

5-10% by 1 year ppm

Failure to normalize cardiac function within 6 months – 85% mortality in 5 years

Question 15

Recurrence rate

Answer 15

20%