Pregnancy-Associated Heart Failure: A Comparison of Clinical Presentation and Outcome between Hypertensive Heart Failure of Pregnancy and Idiopathic Peripartum Cardiomyopathy

Abstract

AimsThere is controversy regarding the inclusion of patients with hypertension among cases of peripartum cardiomyopathy (PPCM), as the practice has contributed significantly to the discrepancy in reported characteristics of PPCM. We sought to determine whether hypertensive heart failure of pregnancy (HHFP) (i.e., peripartum cardiac failure associated with any form of hypertension) and PPCM have similar or different clinical features and outcome.Methods and ResultsWe compared the time of onset of symptoms, clinical profile (including electrocardiographic [ECG] and echocardiographic features) and outcome of patients with HHFP (n = 53; age 29.6 ± 6.6 years) and PPCM (n = 30; age 31.5 ± 7.5 years). The onset of symptoms was postpartum in all PPCM patients, whereas it was antepartum in 85% of HHFP cases (p<0.001). PPCM was more significantly associated with the following features than HHFP (p<0.05): twin pregnancy, smoking, cardiomegaly with lower left ventricular ejection fraction on echocardiography, and longer QRS duration, QRS abnormalities, left atrial hypertrophy, left bundle branch block, T wave inversion and atrial fibrillation on ECG. By contrast, HHFP patients were significantly more likely (p<0.05) to have a family history of hypertension, hypertension and pre-eclampsia in a previous pregnancy, tachycardia at presentation on ECG, and left ventricular hypertrophy on echocardiography. Chronic heart failure, intra-cardiac thrombus and pulmonary hypertension were found significantly more commonly in PPCM than in HHFP (p<0.05). There were 5 deaths in the PPCM group compared to none among HHFP cases (p = 0.005) during follow-up.ConclusionThere are significant differences in the time of onset of heart failure, clinical, ECG and echocardiographic features, and outcome of HHFP compared to PPCM, indicating that the presence of hypertension in pregnancy-associated heart failure may not fit the case definition of idiopathic PPCM.

Peripartum Cardiomyopathy

“…On the other hand, a recent single-center study of 30 patients in Cape Town, South Africa, reported 5 deaths (17%) in a mean follow-up duration of 3.5 years 34 (accounting for the majority of deaths in a larger cohort of 152 patients presenting with cardiovascular disease in pregnancy 86 ). In a larger study of 176 patients in Soweto, South Africa, 13% died and 25% had persistent LVEF <35% at 6 months.…”

“…A recent report directly compared 30 cases of PPCM with 53 cases of hypertension-associated heart failure in pregnancy in a single referral center in South Africa and found that hypertension-associated heart failure typically presented before delivery, was associated with cardiac hypertrophy and preserved EF, and had a better prognosis. 34 Even in the absence of clinical heart failure, a number of echocardiographic studies have shown that preeclampsia causes diastolic dysfunction, measured by various parameters, including E/E', myocardial performance index, and myocardial strain. [35][36][37] The diastolic dysfunction is in part independent from blood pressure elevations and can persist up to 1 year after delivery and resolution of preeclampsia.…”

Peripartum Cardiomyopathy (PPCM): Dual Case Report and Review of Literatures

“…Since there is an overlap of presenting features between PPCM and other hypertensive pathologies such as preeclampsia [14,17,18] such as shortness of breath, fatigue and swelling [8] it is important to be mindful of PPCM and how to diagnose it. Transthoracic echocardiography enables differentiation of heart failure with preserved ejection fraction, commonly observed in women with preeclampsia, from that with peripartum cardiomyopathy in which a reduced ejection fraction is more common.…”

Imbalanced Angiogenesis in Peripartum Cardiomyopathy ― Diagnostic Value of Placenta Growth Factor ―

“…5 In addition, the incidence, contributing comorbidities (e.g., hypertension and pre-eclampsia), and outcome seem to be variable, depending on the geographical region, ethnic background, and the inclusion criteria of the given study. 5, 6 It was recently suggested that PPCM may be associated with increased placental production of soluble fms-like tyrosine kinase-1 (sFlt-1), as in pre-eclampsia, for which it has long been thought to be associated. 7 The antiangiogenic factor sFlt-1 reduces free circulating concentrations of the angiogenic factors placenta growth factor (PlGF) and vascular endothelial growth factor (VEGF) and blunts the beneficial effects of these angiogenic factors on the maternal endothelium.…”

“…6 Clinical assessment, echocardiography, and blood analysis for PPCM patients were performed at the time of admission and hospitalization. Plasma samples were also collected from healthy non-pregnant women (n=29), healthy pregnant women (n=10; 20-36 weeks gestation), and healthy women after delivery (within 24 h of delivery; n=30).…”