HEART FAILURE IN PREGNANCY AND POSTPARTUM

1
HEART FAILURE IN PREGNANCY AND POSTPARTUM

• Uri Elkayam, MD
• Professor of Medicine
• Director heart failure program
• University of Southern California School of
  Medicine
• Los Angeles, California

2
PERIPARTUM CARDIOMYOPATHY

• Definition.
• Incidence.
• Risk factors / associated conditions.
• Maternal outcome.
• Management.
• Subsequent pregnancy.

3
PERIPARTUM CARDIOMYOPATHY

• DEFINITION

4
PREGNANCY ASSOCIATED CARDIOMYOPATHY

• HF in the early postpartum period was recognized
  in the 18th century.
• Cardiomyopathy associated with pregnancy was
  described in 1937.(Am J Med Sci)
• Diagnostic criteria established in 1971.(Demakis,
  Circulation)

5
Peripartum CardiomyopathyDefinitionNIH Workshop
Recommendations and Review 1997, Pearson et al,
JAMA 2000 2831183

• Original ( Demakis et al 1971)
• Development of cardiac failure in the last month
  of pregnancy or within 5 months of delivery.
• Absence of an identifiable cause for the cardiac
  failure.
• Absence of recognizable heart disease prior to
  the last month of pregnancy.
• Additional
• Left ventricular systolic dysfunction
  demonstrated by classic echocardiographic
  criteria, such as depressed fractional shortening
  (lt30) or ejection fraction (lt45).

6
Peripartum CardiomyopathyLimitations of NIH
Definition

• Based on limited number (27) of patients.
• gt90 African Americans.
• diagnosed prior to 1971 in a single institution
  in the US.

7
Peripartum cardiomyopathy - Time of
OnsetDemakis JG, Rahimtoola SH. Circulation
449641971
N 27
Ante Partum
8
Peripartum CardiomyopathyLimitations of NIH
Definition

• Based on limited number (27) of patients.
• gt90 African Americans.
• diagnosed prior to 1971 in a single institution
  in the US.

9
Peripartum CardiomyopathyLimitations of NIH
Definition

• Other studies reported diagnosis of PPCM earlier
  than the last gestational month .
• And in pts with other forms of heart disease
  (Eisenmengers syndrome, VSD, post Fontan
  surgery, Mitral Stenosis, congenital CAD).

10
Pregnancy-Associated Cardiomyopathy Data
Collection (n123)
Survey Forms Mailed To 15,000 Physicians
USC Patients 14 Patients

Self-Referred Cases 33 Patients
Respondents 409 Physicians

Medical Records Reviewed 76 Patients
Diagnosis of PACM 233 Patients
Elkayam et al Circulation 2005111250-5
11
PPCM Time of DiagnosisN123
Weeks
Months PP
12
Patient Population (Traditional Diagnosis)
Number of Patients 100 Age at Diagnosis 16 -
43 years (31 6 years) Age gt30
years 58 Obstetrical History Gravida
1-11 (2.6 2.2) Ethnic Background
Caucasians - 67 Blacks -
19 Hispanics - 10 Asians -
1 Unknown - 3
13
Patient Population (Early Diagnosis)
Number of Patients 23 Age at Diagnosis 20 -
44 years (30 6 years) Age gt30
years 48 Obstetrical History Gravida
1-6 (2.5 1.7) Ethnic Background
Caucasians - 65 Blacks -
17 Hispanics - 4 Asians -
13 Unknown - 0
14
Comparison between Traditionally and Early
diagnosed PPCM patients.
15
Peripartum CardiomyopathyClinical Profile in the
U.S.

• Although PPCM is diagnosed mostly during the 1st
  postpartal month (week), 20 of cases present
  during the 2nd and 3rd trimester prior to last
  gestational month.
• Increased awareness to early presentation should
  allow early diagnosis and appropriate therapy.

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PERIPARTUM CARDIOMYOPATHY NEW DEFINITION

• An idiopathic cardiomyopathy presented during
  the 2nd and 3rd trimester of pregnancy or within
  several months postpartum and associated with
  depressed LV systolic function.

17
PERIPARTUM CARDIOMYOPATHY

• INCIDENCE

18
Peripartum CardiomyopathyIncidence

• Recent surveys in the US and Canada (Circ
  2004110III 520) found a ratio of 1 2500 of
  live births.
• Higher incidence reported in South Africa
  (11,000) and in Haiti (1300 ).

19
Increasing Incidence of PPCM
20
periartum CardiomyopathyClinical Presentation

• CHF signs and symptoms.
• Cardiac and respiratory arrest.
• Arrhythmias.
• Thromboembolism.

21
PERIPARTUM CARDIOMYOPATHY Thromboembolism

• Coronary emboli.
  (Tx heart inst J 200431442).
• Biventricular thrombi.
  (An Med Intern 200421498).
• Pulmonary embolism.
  (Emerg Med J 200421746).
• Peripheral embolization.
  (Ann Cardiol Angiol 200352382).
• Thrombotic cerebral infarct.
  (Can J Anesth 200350160).

22
PERIPARTUM CARDIOMYOPATHY

• MATERNAL OUTCOME

23
Outcome in 123 Patients With PACM

• Recovery Persistent
  Heart Death
• LVEF ?50 LV dysfunction
  Transplantation
• At last F/U at last F/U
• ? ?
  ?
  ?
• 59 41
  4
  10
• Including 2 pts who died post transplantation

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PPCM - Mortality
25
LONG-TERM SURVIVAL IN PTS WITH INITIALLY
UNEXPLAINED CARDIOMYOPATHY(Felker et al NEJM
20003421077)
26
PPCM INTERVAL FROM END OF PREGNANCY TO
DEATHWhitehead et al. Am J Obstet Gynecol
20031021326
27
Maternal Outcomes

• Heart Transplantation 5 Patients
• AICD Implantation 3 Patients
• Permanent Pacemaker 3 Patients
• Deaths 13 Patients
• Sudden Cardiac death 7 Patients
• Post Transplant Complications 2 Patients
• Early progressive CHF
  1 patient
• Unknown Cause 3 Patients

28
PERIPARTUM CARDIOMYOPATHY

• RECOVERY OF LV FUNCTION

29
Left Ventricular Ejection Fraction in 52 Patients
with Complete Set of Measurements
plt0.0000001 vs LVEF at diagnosis
30
PERIPARTUM CARDIOMYOPATHY

• PREDICTORS OF RECOVERY OF LV FUNCTION

31
PREDICRORS OF RECOVERY OF LV FUNCTION IN PPCM IN
THE US(Bitar et all Circulation 2005)
Total Patients 154 Patients
Echocardiogram Data at 6 months Post Partum
unavailable 32 patients
Total Patients Included in Study 122 Patients
32
Left Ventricle EF - outcome at 6 months
56
44
No EF Recovery N54
Recovered EF N68
33


3211
617
2710
556

LVEF recovered
P lt 0.05
Persistent LV Dysfunction
34
Logistic Regression Analysis results
Group 1 (Baseline EF 10-20) Group 2 (Baseline
EF 21-30) Group 3 (Baseline EF 31-45)
35
PERIPARTUM CARDIOMYOPATHY

• HOW NORMAL IS NORMAL LV FUNCTION AFTER PPCM?

36
Contractile Reserve in Pts with PPCM and
Recovered LV FunctionLampert et al, AJOG
1997176189
37
Contractile Reserve in Patients With Peripartum
Cardiomyopathy and Recovered Left Ventricular
Function
Lampert et al. AM J Ob Gyn 1997 176189
38
PPCMMAJOR ADVERSE EVENTS AND RISK PREDICTION

• 172 pts with PPCM.
• 42 pts with MAE (death 13, heart transplant 10,
  CP arrest 6, pull edema 5, TE complications 3,
  AICD 5)
• Mortality 46 sudden death, 46 CHF.
• 37 of the surviving pts had residual brain
  damage.

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PPCMMAJOR ADVERSE EVENTS AND RISK PREDICTION

• MAE preceded the diagnosis of PPCM in 45 of
  cases.
• Diagnosis not made for gt1week from unset of Sis
  1n 40 of cases.
• Predictors of MAE by Cox regression model LVEF
  at diagnosis (p0.0002) and non Caucasian back
  ground (p0.015).

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PERIPARTUM CARDIOMYOPATHY

• ASSOCIATED CONDITIONS

41
peripartum CardiomyopathyReported associated
conditions

• Maternal age gt 30 yrs YES (55)
• Multiple pregnancies YES (58)
• Black NO (20)
• Poor nutrition - NO
• Twin pregnancies YES (15)
• History of HTN / Preeclampsia YES (42)
• Long-term (gt4wks) tocolytic Tx - YES (19)

42
PERIPARTUM CARDIOMYOPATHY

• TREATMENT

43
Peripartum Cardiomyopathy
Therapeutic considerations during pregnancy

• Safe Drugs
• Digoxin
• Nitrates
• Hydralazine
• Heparin
• Diuretics
• Beta blockers

• Unsafe Drugs
• ACE-I
• Nitroprusside
• Amiodarone
• Coumadin
• Experimental Drugs
• Immune globulin
• Pentoxifylline

44
PPCM and Pentoxifylline(Sliwa et al, Eur J heart
fail 20024305)Combined Endpoint of Poor
Outcome(Death, Class III-IV _at_ last FU, Failure
to increase EF gt10)
P0.03
Treatment with pentoxifylline the only
independent predictor of outcome on logistic
regression analysis
45
PPCM and Pentoxifylline(Sliwa et al, Eur J heart
fail 20024305)6 Month Mortality
P0.009
46
PERIPARTUM CARDIOMYOPATHY

• SUBSEQUENT
• PREGNANCY

47
PPCMSubsequent Pregnancy (Elkayam et al NEJM
20013441567)
44 Patients 60 Pregnancies
Group A Normalized LVEF N42
Group B Persistent LV Dysfunction N18
48
Outcome of Subsequent Pregnancies in PPCM
(Elkayam et al NEJM 20013441567)
49
Maternal Complications Associated With
Subsequent Pregnancy

44

31

25
21
21
19

14

0

A B HF Symptoms
A B gt20 Decreased LVEF at F/U
A B Maternal Mortality
A B gt20 Decreased LVEF
including aborted pregnancies
50
Maternal Complications in women without abortions
50

42

33

26
25
17

9

0

A B HF Symptoms
A B gt20 Decreased LVEF
A B gt20 Decreased LVEF at F/U
A B Maternal Mortality
51
Outcome of Subsequent Pregnancies in Women With
PPCM (Elkayam U, Eur Heart J 2002)
plt0.0001 vs. A plt0.01 vs. B p0.01 vs.
B
52
PPCMRISK OF SUBSEQUENT PREGNANCY

• Subsequent pregnancy may lead to a significant
  and persistent depression of LVEF, to CHF and
  even to death.

53
PPCMRISK OF SUBSEQUENT PREGNANCY

• Clinical and functional deterioration is more
  likely in patients with persistent LV dysfunction
  but can also occur in pts who normalize their LV
  function.