What can you do if not recovered?

[JAMESFETT]

What can you do if you have PPCM and you haven't yet improved beyond LV EF 45 % more than 6 months after diagnosis? I spend a lot of time talking with doctors and patients about just that question. Here are a few questions I ask:

1)Have the maximum tolerable dosages of ACE-I and B-B been reached? If not, it is worth working dosages up, one medicine at a time, and periodically checking with "quick-look" echocardiogram, to know if there is response.

2)Is the diagnosis of PPCM correct? Or could there be a different cause for the heart failure and cardiomyopathy?

3)Have blood tests been done for both hsCRP and BNP? Both of these may help to identify ongoing cardiomyopathy problems.

4)Has a cardiac MRI been done, using gadolinium injection, looking for late gadolinium enhancement, trying to understand if there is inflammation and/or scarring in the heart muscle?

5)Has progress been slow enough to warrant doing an endomyocardial biopsy at a center experienced in doing this? While EMB is not done commonly in PPCM, I believe there are a number who should be biopsied when they either a)fail to continue to improve when LVEF <40 % or b)are in the process of deteriorating further.

6)Is "cardiac syncronization" therapy indicated to use electrical stimulation, a type of pacing, in order to gain a more coordinated contraction with better cardiac output?

7)If anemia is present has it been corrected? This will result in less stress on the heart.

JD

[momof3]

Thank you for the information Dr. Fett. I have an echo scheduled in June that I am very anxious about. Do you know Dr. Jessup at Penn? I hear she is the best and I trust her very much. I will bring your recommendations with me to my appointment. Hopefully, my EF will be above 45% but I have a feeling it won't. I am still very tired, and at my last echo in Dec. my EF had only improved to 20%.

[SusanD]

Dr.Fett, Tabs and I have been privately discussing the concept of "rest" and PPCM patients. I know right now the recommendation of rest is not well defined in the PPCM population nor is the advice given with any consistency. We do know there are reports of near recovery for CM patients put on an LVAD, so why isn't physical rest recommended more of the time?

I think too many women are told they can return to physically demanding jobs PLUS taking care of babies and home when their EF is barely 35-40%.

When my EF was that low, I was not allowed to work. My cardio told me specifically not to be doing any housekeeping, heavy lifting, strenous work, etc. I *was* allowed to do a low level monitored cardiac rehab program, but he specifically told me to rest every afternoon. I still believe that was a vital piece of my recovery.

[momof3]

My Ef is 30% and I know there is no way I can go back to work. I am a teacher and being on my feet all day would not work. My cardiologist also told me I need to rest every afternoon. By 2 pm I literally fall asleep as soon as my head hits the pillow.

[JAMESFETT]

It's a fine line between sufficient effort after acute stage to improve heart function and conditioning and the rest needed in acute stage to avoid excess stress on the heart. Animals in acute myocarditis that were required to exercise on wheels did worse than those that rested, in terms of recovery of heart function.

Hopefully, the pending USA study, "Immune Activation and Myocardial Recovery in Peripartum Cardiomyopathy" will lead to better clues about interventional trials of non-conventional treatments for those who are not recovering in a timely manner as hoped for and as experienced by 50 to 60 % of PPCM patients.

JD