No abstract

Peripartum cardiomyopathy is a rare and a severe form of heart failure that affects women during pregnancy or shortly after delivery. Risk factors include advanced age, race, multiparity, multifetal pregnancy, socioeconomic disparity, and medical comorbidities including systemic hypertension, diabetes, asthma, and anemia. Peripartum cardiomyopathy is associated with increased morbidity and mortality, as well as a detrimental long-term impact on quality of life. Its etiology is not clear, although it is thought to be a combined effect of a hyperdynamic fluid state associated with pregnancy, hormonal changes unique to gestation, and a genetic predisposition. There is no current expert consensus on an optimal treatment regimen. This article will provide a comprehensive review and update on this important disease state.

Mineralocorticoid receptor antagonists (MRAs) are known to have a proven mortality benefit in heart failure with reduced ejection fraction (HFrEF) without kidney disease. As patients with end-stage renal disease (ESRD) requiring either peritoneal dialysis or hemodialysis were excluded in clinical trials of HFrEF, the data are scant on the appropriate use of MRAs in this population. The unknown efficacy, along with concerns of adverse effects such as hyperkalemia, has limited the willingness of clinicians to consider using MRAs in these patients. However, it is unclear whether the risk of hyperkalemia is present if a patient is oliguric or anuric. Current guidelines recommend against the use of MRAs in patients with chronic kidney disease, but do not address the use of MRAs in patients requiring dialysis. This article will review the epidemiology of heart failure in ESRD, the pathophysiological derangements of the renin–angiotensin–aldosterone system in patients with kidney disease, and the results from case series and trials of the use of MRAs in ESRD with HFrEF. Although limited to several small trials using MRAs in peritoneal and hemodialysis patients with or without HFrEF, the current literature appears to show the potential for clinical benefits with little risk.