Question for Dr. Fett (long)

[kristikm]

Dr. Fett,

I have a question about my PPCM diagnosis. I had an uneventful c-section with my third child in April. I had insulin-dependent gestational diabetes. Seven days postpartum, I ended up in the ER with shortness of breath (I was convinced it was Asthma), +2 pitting edema in my legs, a temp of 101 degrees and a BP of 198/114. I was feeling fine during all of this other than some visual disturbances and back pain. My labs were normal other than a BNP of 229, elevated liver enzymes, and minor indications of a urinary tract infection. I had several diagnoses over the three days I was in the ER and at the hospital: Right-Sided heart failure, Congestive Heart Failure, Elevated BNP possibly due to postpartum state with volume changes, and mild PPCM. The cardiologist finally told me he believed it was PPCM. After looking at this sight, I am questioning the diagnosis based on the records I have from the hospital. My EF was not low enough to meet the criteria for PPCM as it is recorded to have been "50-55% 2D bedside with no significant valvulopathy. RV appears underfilled." My EKGs only noted "possible left atrial enlargement". Should I be concerned about having a correct diagnosis, or should I just be happy that my BNP is down to 17, liver enzymes have normalized, and my blood pressure, though still a bit elevated is no longer significantly high? I am not on any medications and my only complaint is that my heart seems to be beating really hard at times, have some trouble breathing from time to time and dizziness when I first stand up. I have a follow-up echo in November. Any thoughts would be appreciated. Thanks. -Kristi

[heartfulloflove]

Hi there. I'm obviously not Dr. Fett, but I have a similar situation to yours. I also had an uneventful birth (vaginal) at Christmas last year and went home feeling fine except for some chest discomfort and concurrent bradycardia (45 beats per minute). I was told it was from volume changes and labor/delivery, etc. and didn't worry.

I became increasingly short of breath, and one night frighteningly so...I was almost gasping for air just picking up some little toys in my toddler's room! I also had chest pain. I went to the ER and a chest x-ray and EKG were normal. My BNP wasn't checked but the other stuff was fine. This was 6 weeks postpartum.

A couple months later, when I attempted to exercise, I began having severe palpitations and my heart rate shot up to 200+, and the more I tried the worse it got. The third day of this I finally went to the ER (St. Patricks Day). Everything checked out fine. In fact, I did not have ONE single palpitation for my whole four hours in the ER. I was told, however, to see a cardiologist before exercising any more.

I did, on March 21. Everything was normal until the echo. My heart was slightly enlarged at end systole, and my ejection fraction was 49%. Immediately my cardiologist suspected PPCM and told me he would be starting me on medication to "help shrink my heart". He ordered a Cardiolite Stress Test for the very next day, and I went home wearing a Holter monitor with orders to lift nothing more than 20 pounds and do no exercise until we had the Holter results.

The next day I had the Cardiolite test. One week later I was told that my results were completely normal, including my EF (57%) and my heart size. I asked him if he thought anything had been wrong at all, and he said he stands my his initial impression. He did lift all restrictions (except weightlifting) and opted not to medicate me. I've had re-checks every 2 months since and everything's about the same.

Like you, I wonder if I should question it or just be REALLY SUPER HAPPY! I'm on the fence. My EF was basically normal on the echo (visually he said it appeared to be 60%, which was confirmed with the Cardiolite test at 57%). Was there something really wrong with you or I? My guess is that we both had a mild something. I wish I knew what my BNP was back in January, because I think that would have given a definitive answer.

I also get the hard heart-beating (usually it means I am dehydrated) and dizziness when I stand up (also, usually dehydration). Are you making sure to get enough water? Just a thought.

Anyway, just sharing my experience with you. Glad you're doing well other than those couple of annoying symptoms.

Edit: yeah, forgot to add that bit about fractional shortening until Dr. Fett responded. Mine was 25, which technically puts me in the PPCM criteria. I was all relieved until I learned about FS.

[JAMESFETT]

First, I'm glad you are doing so well. You are correct, you did not meet the EF criteria for a diagnosis of PPCM. The echo criteria, added after the original description of PPCM back in the 60''s, also include criteria for "Fractional Shortening" or ''FS,'' with FS criteria of "less than 30 percent." You may want to make that calculation, but to do so you need to know the following dimensions from the echo:
End-diastolic dimension (EDD)
End-systolic dimension (ESD)

and plug into the formula:

FS = EDD - ESD divided by EDD

Example 6.0 cms - 4.5 cms divided by 6.0 = 0.25 or 25 percent.

Feel free to get back to me with those numbers if you find them. In any case, your up-coming echo will be important; and it is great that you are now doing so well.

JDF

[JAMESFETT]

One caution: the presence of diabetes may give a flasely-elevated BNP, which is not a true reflection of left ventricular failure. I don't know the ''cut-off'' level of BNP at your lab, but that value in any case does not seem to be very elevated; so again, you may not have had left ventricular failure; and if you did not then you certainly didn't merit a diagnosis of PPCM. On the other hand elevated liver function tests can reflect passive congestion of the liver from heart failure. So did you or didn't you have at least mild heart failure? I don''t expect you to know the answer to that, because I don't.

JDF

[kristikm]

Dr. Fett,

Thank you for your reply. I had heart clinic look up my records for me on my echocardiogram and the numbers I was given are:

EDD: 4.40
ESD: 3.29

4.4 - 3.29 =1.1 divided by 4.4 = .25

Did I calculate this correctly? The nurse gave me the "normal" range for both the EDD and the ESD and mine were both within that range. I was also curious to know if the medications I had been taking at the hospital could have increased my EF since they had been giving me several different medications IV as well as Lasix prior to doing the echo. I'm not sure why they waited so long to do the echo. I started at the Emergency Dept. on a Thursday and didn't have the echo until Saturday. They had my BP stabilized and I had lost 14 lbs of water by then. I then had another one done a week later at the heart clinic and that is the one from which the above numbers came. Again, thank you so much for sharing your insight.

Kristi

[JAMESFETT]

Yes, you did the calculation correctly. Your FS of 0.25 or 25 percent does meet the recommended echo criterion for a diagnosis of PPCM. In addition, with the treatment and diuresis (loss of water weight) in the interval from starting treatment to the time when echo first done, it is very likely that both FS and EF would have been lower had an echo been done prior to starting treatment. Those are important considerations.

JDF

P.S. a normal EDD is 2.7 cm per meter squared body surface area (BSA), so knowing your height and weight (non-pregnant) it is possible to calculate your body surface area using a nomogram. I will be glad to do that for you if you let me know your height and non-pregnant weight. Depending upon a person's size and body surface area, an EDD of 4.4 cm left ventricle may be either normal or abnormal. Example: body surface area 1.3 would give an EDD/meter squared BSA of 3.4 cm (abnormal) while a body surface area of 1.7 would give an EDD/meter squared BSA of 2.6 cm (normal)

[JAMESFETT]

P.S. Normal "postpartum state" and volume changes will not cause an elevation of BNP. I assume you had your BNP determination done initially before treatment started, and not at the time of your echo.

JDF

[kristikm]

Dr. Fett,

The BNP cut off at the lab was 100. The BNP was not done until I had already started on Hydrolozine IV. They drew blood prior to this, however, they lost the vial and had to redraw. The BNP after all my hospital treatment, prior to release, was 176. It was drawn again two months later and was down to 17. My blood sugars started dropping a week before my c-section and have been normal on all lab work following.

I would be interested in finding out what a normal EDD is for me. I am 5'5" and 140 lbs.

I appreciate finally getting some answers to the questions I have been having for several months. Thank you so much for your time.

Kristi

[JAMESFETT]

With those measurements, your body surface area (BSA) is 1.6 square meters. This permits a calculation of left ventricle size based upon your height/weight as follows:

EDD of 4.4 cm divided by 1.6 = 2.75 cms per square meter BSA.

The PPCM echo criterion for abnormal size left ventricle is "greater than 2.7 cms per square meter BSA."

This places you just very slightly above the stated level, and could be interpreted as "upper range of normal" or "lower range of abnormal." I wouldn't get overly concerned with that,however, because frequently with early PPCM the size of the left ventricle is not significantly enlarged; and early the more important measures are EF and FS.

I think probably your BNP levels would have been higher prior to any treatment, since both diuretics and IV hydralazine importantly impact upon acute heart failure; and of course the IV hydralazine also importantly impacts upon the hypertension, whether caused by "hypertension of pregnancy" or "toxemia (pre-eclampsia) of pregnancy."

JDF