High-output heart failure in PPCM?

[Sam]

Hi Dr. Fett ~

I just came across the following study that found that some patients with PPCM actually have high output failure and normal to near-normal ejection fractions. It’s the only reference I can find that has stated that someone can have a normal EF with PPCM.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=1985355&dopt=Abstract

I know that the criteria for a PPCM diagnosis has changed to include an EF of 45% or less. I was just wondering if you could give me your thoughts on this study. If it is possible to have high-out failure with PPCM, why was the criteria changed to include the echocardiographic criteria?

After the delivery of my son, I had mild to moderate anemia that was progressing before they decided to put me on iron supplements when I was discharged from the hospital. In my cardio’s report after he performed his physical examination of me (but before he viewed my echocardiogram), he stated that my anemia may have been contributing to a component of high-output failure, as well. I’m taking this to mean it’s possible to have low-output and high-output failure at the same time. If so, how would this affect someone’s EF?

Thanks again for your time!

~ Sonja

[JAMESFETT]

by definition, "high output" failure would not be PPCM. It would be another condition, such as Beri-beri (Thiamine deficiency). Original descriptions of PPCM came into modern descriptions before echocardiographic info available, and the specific echo criteria (EF less than 45 %, FS less than 30 %) came later.

JDF

[heartfulloflove]

What if your EF is normal and your FS is 25?

[Erin]

Sorry to interrupt -- what does "FS" mean?

Thanks.

[JAMESFETT]

the definition was added to signs and symptoms of heart failure in Hibbard's article [Obstetrics Gynecology 1999;94:311-6] as an additional criterion the echo findings of left ventricular systolic function as "less than 45 % EF or less than 30 % FS (Fractional Shortening). We accept either EF or FS as qualifying. In earlier reports the only measure available was FS.

JDF

[Sam]

Hi Dr. Fett ~

Just for clarification, if someone had low-output heart failure (as in PPCM), but they also had an anemia at the same time that was causing a high-output failure, as well, would this affect one's ejection fraction . . . meaning could these two conditions occurring at the same time sort of cancel each other out and make the EF normal or near normal?

I'm assuming the answer is no since pregnancy itself is a high-output state and some women with PPCM diagnosed before delivery present with a low EF, but I just want to make sure that the postpartum anemia I had developed wouldn't be confusing anything in my case.

Thanks, again, for your time!

~ Sonja

[tabs]

Just a quick question.....What is high-output failure? Is it the same as diastolic heart failure? If it is the same, then wouldn't that in itself disqualify it from being PPCM which is a dilated cardiomyopathy?

Twilah

[Sam]

Hi Twilah ~

The way I understand it, high-output HF and diastolic HF are two different entities. High-output HF is when the body's need for blood is elevated so the heart goes into a "hyperdynamic" state in trying to meet the body's increased needs.

It is much less common than low-output heart failure or diastolic dysfunction, and there are certain conditions that can cause it (i.e. anemia, hyperthyroidism, and even pregnancy). While the ejection fraction can be normal in both diastolic dysfunction and high-output, it can also be elevated above normal levels in high-output HF.

My cardiologist thought maybe that my anemia may have been playing some part in my HF (this was before he saw my echo, though, and it's never been mentioned since, so I'm not sure if he changed his opinion on this or not). So I was just wondering how low-output and high-output, if occurring at the same time, would affect the EF.

I hope this was helpful!

~ Sonja

[JAMESFETT]

yes, you are right. However, anemia is always a negative factor, and makes any heart failure worse, because the anemia is a message to the heart to work harder to meet the body's oxygen needs, and in the case of dilated cardiomyopathy with systolic dysfunction (like in PPCM) the heart just can't perform, unable to respond to the oxygen needs of the body.

JDF

[tabs]

Sam, Thank you! I had just finished a reveiw of HF types and had not come across that term. I love gaining new understandings hence why I just finished my Master's of Nursing even though I am still not allowed to work.:)

Dr. Fett,

Thank you. That makes more sense as I was anemic as well. I know that it became such a concern with my low EF that they risked a transfussion. I was pretty sure that they were concerned about decreasing my EF even further if they did not do the transfussion, but........I was so sick at the time that I could have easily confused things in my mind.;)

I do have one question about the abstract provided in the original link though. It seems that they were looking at the PPCM patients 3 months into their dx. Could this have contributed to their findings as possibly some of them had already recovered their EF or was I just reading the abstract wrong?:o

Thanks,
Twilah

[JAMESFETT]

I suggest no one try to make too much of the study because it contains a mixed group of patients that do not all fit the accepted criteria for a diagnosis of PPCM. It reflects pre-2000 understanding of PPCM. We have made a lot of advances since that time in our understanding of PPCM. There have been some very good studies on PPCM coming out of Brazil, but many of the earlier studies, particularly before 2000, contain data on patients who have not fulfilled all the currently accepted criteria for a diagnosis of PPCM.

JDF

P.S. The women who do not fit the criteria for PPCM would be classified "pregnancy-associated heart failure" and we can't compare them with accepted definition of peripartum cardiomyopathy.