Exercise Stress Echo

[jeannie]

Ok I spoke with the cardiologist and found my beginning ef to be at 55 and it went to 65 at target heart rate. Do those results sound ok?

[JAMESFETT]

Terrific! That is an 18 % increase, and is well within the defined "adequate" contractile reserve. That does not guarantee no relapse with a subsequent pregnancy, but the data support that a relapse is much less likely in that situation. Careful monitoring during the subsequent pregnancy is indicated.

For the benefit of others who may be recovered to the level of LVEF 55 %, and have an exercise stress echo that shows either a drop in the LVEF or less than 15 % or 10-point increase, that would indicate incomplete healing and inadequate contractile reserve. In that situation, deferring a subsequent pregnancy to allow more time for healing would be recommended.

Congratulations to you and best wishes.

JD

[SarahG]

Hi Dr. Fett,

I haven't had a question for you in quite a while, but now that some time has passed since my miscarriage, I'm starting to think about another baby and I have a question that goes along the same lines as this thread.
My EF has always hovered at 50% - sometimes read as 50-55% or 45-50% depending on what, I don't know. I've had absolutely no symptoms since DX (it's been 2 1/2 years) although I had some V-Tach at DX, so I'm still on Coreg. My stress echo in September '09 showed that my resting EF was 45-50% but during exercise it went up to 65%. I know that ideally you'd have an EF of 55% AND normal contractile reserve, but with my EF hovering around normal with the normal contractile reserve, what would you recommend? What do you think my risk of relapse or death would be with a subsequent prenancy?

Thank you again for everything!
-Sarah

[JAMESFETT]

That's a nice gain on your stress echo. I wish the resting baseline were more towards the LVEF 55 %. We just don't have any observations on those in your situation, i.e. with a resting LVEF < 50 but a good exercise response. What we do have is the observation that with a resting LVEF of 55 % or more, AND adequate contractile reserve on exercise stress echo, we have so far seen no one with relapse. We also see that if the resting LVEF is > 50 %, and there is a relapse on the post-PPCM pregnancy, there is a very good chance that full recovery will occur again to LVEF > 50 %. So those are at least 3 scenarios that we are juggling and the prospects go from very good, to intermediate to not so good.

JD

[jeannie]

I read the articles with my ob that you sent to me. Are we to understand that at this time there have not been any relaspes with anyone who had an ef above 55 and a adquate gain on their exercise stress echo?

[JAMESFETT]

Yes, that is correct for those for whom the two criteria apply (LVEF of 55 % or above, and adequate contractile reserve on exercise stress echo as defined). I am looking for anyone who meets those two criteria and still has a relapse of heart failure with a subsequent pregnancy. I suppose with time, we will identify someone like that, but so far, no one.

The other encouraging factor is that for those who start the subsequent pregnancy with LVEF 55 %, but have not had the stress echo done, should those women relapse (approximately 20 % of the 26 observed) with heart failure during or following a post-PPCM pregnancy, all observed, with appropriate treatment of the relapse, have recovered to pre-subsequent pregnancy LVEF. There are, of course, no guarantees.

And, by contrast, those who begin the post-PPCM pregnancy with LVEF < 50 %, have a greater risk of NOT regaining the pre-subsequent pregnancy LVEF if they have a relapse of heart failure--in other words, more likely to have permanent damage to the heart muscle.