1 January 2008: Did you know?

[admin]

Did you know?:

Current conventional heart failure therapy of PPCM with diuretics, ACE-inhibitors (or hydralazine/nitrates if still pregnant), and beta-blockers results in an unprecedented survival of almost every PPCM patient.

Current therapy of PPCM results in improvement in almost every PPCM patient and complete recovery of heart function in almost two-thirds of patients.

Successful subsequent pregnancy is possible in most PPCM patients who have fully recovered heart function, although careful monitoring for relapse is necessary. There is effective treatment available for those who relapse.

IF you have PPCM and IF you are slow to recover (left ventricular EF below 20 per cent at two months after diagnosis or below 40 percent at 3months after diagnosis) or inability to maintain sufficient circulation at any time after diagnosis (called "hemodynamic instability") it is important to be considered for additional evaluation, including cardiac magnetic resonance imaging (helpful only when positive enhancement), cardiac catheterization, and endomyocardial biopsy BECAUSE you could be a candidate for non-conventional treatment that may give a boost to recovery.

Never lose hope.

JD

[Erin]

Dr. Fett -- I was given some information and wondered if you could verify or nullify/update it for me and point me to a journal of medicine article that supports newer findings, if that's possible. I was told that "mortality rates [for PPCM] range anywhere between 9 - 56%," and this reference was cited: Ravikishore AG, Kaul UA, Sethi KK, Khalilullah M. Peripartum cardiomyopathy: prognostic variables at initial evaluation. Int J Cardiol. 1991 Sep;32(3):377-80. I haven't been able to access the source myself to verify, but it's dated 1991 anyway, and I'm assuming there is much more recent info available?

Thanks for your help.

Erin

[JAMESFETT]

That is definitely outdated. Here is a more recent article with the much higher survival rates (no deaths), more accurately reflecting newer treatments:

Am Heart J. 2006 Sep;152(3):509-13. Links
Improved outcomes in peripartum cardiomyopathy with contemporary treatment.
Amos AM, Jaber WA, Russell SD.
Division of Cardiology, Duke University Medical Center, Durham, NC, USA.

BACKGROUND: Prior studies have shown both high morbidity and mortality for patients with peripartum cardiomyopathy (PPCM). These studies were small and predated current advances in heart failure treatment. We sought to determine the outcomes of women with PPCM in the contemporary era and to determine predictors of poor outcome. METHODS: Patients with PPCM from 1990 to 2003 were identified retrospectively through screening of heart failure clinics and echocardiography records. Their records were reviewed, and current clinical status was determined. RESULTS: Fifty-five patients were identified with an average follow-up of 43 months. Their mean initial ejection fraction (EF) was 20%. Compared with their initial EF, 62% of patients improved, 25% were unchanged, and 4% declined. No patients died, and 10% eventually required transplant. At 2 months after diagnosis, 75% of those who eventually recovered had an EF >45%. Factors associated with lack of recovery at initial assessment were a left ventricular (LV) end-diastolic dimension >5.6 cm, the presence of LV thrombus, and African-American race. Recovery of LV function was not predicted by the initial EF. Among patients who recovered, the withdrawal of heart failure medications was not associated with decompensation over a follow-up of 29 months. CONCLUSIONS: The morbidity related to PPCM is less than previously reported. Initial LV end-diastolic dimension and EF at 2 months predict long-term outcomes. The discontinuation of heart failure medications after recovery did not lead to decompensation.


This reference can also be seen in the forum for patients and health professionals (along with 9 other important recent PPCM articles) under the thread "For you and your physicians."

JD

[JAMESFETT]

The most current reports about outcomes in treatment of PPCM in the USA come from:

Felker, Johns Hopkins, (n= 44) with 93+ % survival, 7 % transplants

Amos, Duke, (n = 55) with 100 % survival, 10 % transplants

McNamara, U Pitt, (n =17) with 100 % survival, no transplants.

These are very encouraging.

JD

[Erin]

Thank you, Dr. Fett, this is very helpful.

[Erin]

P.S.

Dr. Fett, is there a citation for the McNamara, U Pitt study yet?

Thanks again.

[JAMESFETT]

Left ventricular recovery in peripartum cardiomyopathy: Impact of beta-blockade. Circulation 2007;116, October 16, Supplement II, page 551, Abstract #2500.

It may be harder to find the article because it is a supplement to Circulation. Also, some of the most important information is in the oral presentation, but not in the written abstract. If you want to listen to the presentation, we have posted that on another thread. Both presentation and discussion following are on that audio. Here's a copy of that thread:

Here's the website for the CRP in PPCM presentation at Orlando 2007 American heart Association, along with audio. to play, right click the play button at the bottom, then left click the play option.

http://www.scienceondemand.org/focus...AOP.57.3a.7491

and here's the PPCM presentation about beta-blockers (anne identified the address earlier):

http://www.scienceondemand.org/focus...AOP.60.1.10169

NOTE: you'll have to go back to that thread from 15 December 2007 on the research forum to get the connection to work.




JD

[admin]

This article points out increased awareness of the importance of PPCM in maternal mortality in the USA. Fortunately, with this increased awareness comes the improving survival and recovery rates from PPCM. This all means that PPCM is finally being better understood by the medical community and the population served:

Best Pract Res Clin Obstet Gynaecol. (javascript:AL_get(this, 'jour', 'Best Pract Res Clin Obstet Gynaecol.');) 2008 Jan 5 [Epub ahead of print]
Maternal mortality in the United States.

Lang CT (http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Lang%20CT%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus), King JC (http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22King%20JC%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus).
Maternal–Fetal Medicine, The Ohio State University College of Medicine, Columbus, USA.
Despite a significant improvement in the US maternal mortality ratio since the early 1900s, it still represents a substantial and frustrating burden, particularly given the fact that - essentially - no progress has been made in most US States since 1982. Additionally, the US Centers for Disease Control and Prevention has stated that most cases are probably preventable. Two disheartening issues within this topic include a gross underestimation of the magnitude of maternal mortality - particularly before 1987, but which likely persists to a lesser degree today - and the continued significant racial disparity in maternal mortality. Explanations for the plateau in maternal mortality include the recent trend of delayed childbearing, with the potential accompanying complications associated with older reproductive age (particularly over 35 years) and multiparity. The impressive increase in multifetal pregnancies related to delayed childbearing and assisted reproductive technology also plays a role. Finally, peripartum cardiomyopathy has become an increasingly recognized source of maternal mortality. Pregnancy-related mortality is largely accounted for by thromboembolic disease, hemorrhage, hypertension and its associated complications, and infection. However, since the inclusion of maternal deaths occurring after 42 days post-delivery as pregnancy related, traumatic injuries - including homicides and suicides - are an alarming source of maternal mortality.