Med History

[Erin]

Dr. Fett, I was looking over my hospital records and wonder what you think about this. I had heart failure symptoms when I delivered my twins, but apparently my EF was 55-60% the week of delivery. I was released from Labor and Delivery with a diagnosis of mitral valve regurgitation and enlarged heart. I saw a cardiologist four days later who said I had acute heart failure and possibly PPCM and had me immediately readmitted to the cardiac unit that day. I had another echo. This one put my EF at 35-40%. The two echos were only a week apart.

Is it possible that my EF changed that quickly? Or is it more likely that the first echo was somehow a mistake? I've just always wondered this. Is it likely that my first echo could be in the normal range while I was having heart failure symptoms (i.e., SOB, extreme fatigue, sinus tachycardia, etc.)?

Just wondered about your thoughts on this.

Thanks.

[JAMESFETT]

The EF can change very quickly, just in a matter of hours, when it is going South (deteriorating). I am often quite amazed at the rapidity of worsening when the process is in full swing. That's why I am always concerned about any delays in diagnosis, since recognition with appropriate treatment can be both life-saving and critical in the ability to recover function.

Your release with "mitral valve regurgitation and heart enlargement" certainly suggests that PPCM was in progress, since the mitral regurg is very common due to stretching of the mitral valve ring with left ventricular dilatation.

I would trust both results, and accept the fact that your PPCM process was in development and worsening. It is possible to have the symptoms even with relatively preserved numbers, although obviously the deterioration was in progress and you were on the "edge of the precipice." Had they been done, I would suppose your blood BNP and hsCRP would have been elevated at that time.

JD

[Erin]

This is fascinating. It does say I had myocarditis before being diagnosed with PPCM, too -- isn't that what hsCRP would have indicated?

You may or may not also recall that some months after my diagnosis, having learned about CRP from you, Dr. Fett, I requested an hsCRP and it was elevated to 10.6 mg/L. A few months ago it was reduced to 3.4 mg/L.

What is "normal" range for CRP? Should I expect it to decrease again? Is it important to repeat the test to make sure it returns to normal range?

Thanks again for your response. I am still amazed as I continue to put this all together.

[JAMESFETT]

PPCM = inflammatory cardiomyopathy = myocarditis. You fit the pattern. With recovery I expect to see the plasma hsCRP stay in the lower range, such as you have now. With PPCM starting or frelapsing, such as during a subsequent pregnancy, I expect to see plasma hsCRP > 10 mg/Liter. More often, plasma hsCRP testing is used to determine risk for coronary artery disease, in which < 1 mg/L is associated with low risk, 1 -3 mg/L associated with moderate risk, and >3 mg/L associated with higher risk fo coronary artery disease. That would not, however, apply to you since your elevation was related to a cardiomyopathy. Most interesting.

JD

[Stephanie'sbigheart]

I have been reading these threads for months now and I am not sure I really understand the difference between PPCM and heart failure. Can anyone explain in simple terms? Thanks!

[JAMESFETT]

Heart failure is state of insufficient circulation of blood caused by decreased heart muscle function. There are two forms of heart failure: systolic and diastolic. PPCM is one cause of systolic heart failure. Of course there are varying degrees of severity, and the heart failure may occur with or without symptoms.

JD

[Erin]

Okay, I went back to my records and the myocarditis isn't mentioned until my diagnosis of PPCM, so that makes sense to me now.

On the final discharge paper it says, "Pregnancy induced cardiomyopathy with myocarditis. Myocarditis diagnosed with CK of 118 and CK MB of 8.4 giving index of 7.1, troponin, however, has been normal at 0.03." What does that mean, if you'll indulge my curiosity?

Thanks, Dr. Fett.

[JAMESFETT]

Those are lab measures of blood tests of enzymes from damaged heart muscle. The myocarditis of PPCM may or may not show elevations of those, and frequently does not. The plasma hsCRP appears to be more sensitive than any of those and more frequently elevated at the time of diagnosis of PPCM--uniformly so in every case from our studies, but of course there are always exceptions to any rule or observation. I do see why they would say "myocarditis" and that is appropriate. Those same tests may be elevated with coronary artery disease and myocardial infarction--which of course you never had.

JD

[Erin]

Is it a goal for hsCRP to become a standardized diagnostic tool, meaning that it would be administered upon suspicion of PPCM commonly?

So it sounds like in my case I was diagnosed really very early then?

[JAMESFETT]

Yes, indeed, it would seem that your diagnosis was made early in the course of PPCM. Yes, hopefully, a blood hsCRP would be done in every patient with PPCM, because it helps to see an elevated level to confirm an inflammatory cardiomyopathy, and with treatment it is helpful to see the rather rapid decrease, indicating effectiveness of treatment. And in subsequent pregnancy it may alert early to a developing relapse.

JD