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

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          Abstract

          Aims

          There 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 Results

          We 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.

          Conclusion

          There 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.

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          Most cited references40

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          Hypertensive disorders and severe obstetric morbidity in the United States.

          Carma Ayala, Elena V. Kuklina, W Callaghan (2009)
          To examine trends in the rates of hypertensive disorders in pregnancy and compare the rates of severe obstetric complications for delivery hospitalizations with and without hypertensive disorders. We performed a cross-sectional study using the 1998-2006 Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project. Logistic regressions and population-attributable fractions were used to examine the effect of hypertensive disorders on severe complications. The overall prevalence of hypertensive disorders among delivery hospitalizations increased significantly from 67.2 per 1,000 deliveries in 1998 to 81.4 per 1,000 deliveries in 2006. Compared with hospitalizations without any hypertensive disorders, the risk of severe obstetric complications ranged from 3.3 to 34.8 for hospitalizations with eclampsia/severe preeclampsia and from 1.4 to 2.2 for gestational hypertension. The prevalence of hospitalizations with eclampsia/severe preeclampsia increased moderately from 9.4 to 12.4 per 1,000 deliveries (P for linear trend <0.001) during the period of study. However, these hospitalizations were associated with 38% of hospitalizations with acute renal failure and 19% or more of hospitalizations with ventilation, disseminated intravascular coagulation syndrome, pulmonary edema, puerperal cerebrovascular disorders, and respiratory distress syndrome. Overall, hospitalizations with hypertensive disorders were associated with 57% of hospitalizations with acute renal failure, 27% of hospitalizations with disseminated intravascular coagulation syndrome, and 30% or more of hospitalizations with ventilation, pulmonary edema, puerperal cerebrovascular disorders, and respiratory distress syndrome. The number of delivery hospitalizations in the United States with hypertensive disorders in pregnancy is increasing, and these hospitalizations are associated with a substantial burden of severe obstetric morbidity. III.
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            Peripartum cardiomyopathy: National Heart, Lung, and Blood Institute and Office of Rare Diseases (National Institutes of Health) workshop recommendations and review.

            Anees Ansari, S Rahimtoola, J Veille … (2000)
            Peripartum cardiomyopathy (PPCM) is a rare life-threatening cardiomyopathy of unknown cause that occurs in the peripartum period in previously healthy women. In April 1997, the National Heart, Lung, and Blood Institute (NHLBI) and the Office of Rare Diseases of the National Institutes of Health (NIH) convened a Workshop on Peripartum Cardiomyopathy to foster a systematic review of information and to develop recommendations for research and education. Fourteen workshop participants were selected by NHLBI staff and represented cardiovascular medicine, obstetrics, immunology, and pathology. A representative subgroup of 8 participants and NHLBI staff formed the writing group for this article and updated the literature on which the conclusions were based. The workshop was an open meeting, consistent with NIH policy. Data presented at the workshop were augmented by a MEDLINE search for English-language articles published from 1966 to July 1999, using the terms peripartum cardiomyopathy, cardiomyopathy, and pregnancy. Articles on the epidemiology, pathogenesis, pathophysiology, diagnosis, treatment, and prognosis of PPCM were included. RECOMMENDATION PROCESS: After discussion of data presented, workshop participants agreed on a standardized definition of PPCM, a general clinical approach, and the need for a registry to provide an infrastructure for future research. Peripartum cardiomyopathy is a rare lethal disease about which little is known. Diagnosis is confined to a narrow period and requires echocardiographic evidence of left ventricular systolic dysfunction. Symptomatic patients should receive standard therapy for heart failure, managed by a multidisciplinary team. If subsequent pregnancies occur, they should be managed in collaboration with a high-risk perinatal center. Systematic data collection is required to answer important questions about incidence, treatment, and prognosis.
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              Pregnancy-associated cardiomyopathy: clinical characteristics and a comparison between early and late presentation.

              Fadi F. Bitar, Uri Elkayam, W Akhter … (2005)
              Cardiomyopathy associated with pregnancy was first described more than half a century ago. However, because of its rare occurrence and geographical differences, the clinical profile of this condition has remained incompletely defined. Data obtained from 123 women with a history of cardiomyopathy diagnosed during pregnancy or the postpartum period were reviewed. One hundred women met traditional criteria of peripartum cardiomyopathy; 23 were diagnosed with pregnancy-associated cardiomyopathy earlier than the last gestational month. Peripartum cardiomyopathy patients had a mean age of 31+/-6 years and were mostly white (67%). Common associated conditions were gestational hypertension (43%), tocolytic therapy (19%), and twin pregnancy (13%). Left ventricular ejection fraction at the time of diagnosis was 29+/-11% and improved to 46+/-14% (P 30% at diagnosis. Maternal mortality was 9%. A comparison between the peripartum cardiomyopathy and early pregnancy-associated cardiomyopathy groups revealed no differences in age, race, associated conditions, left ventricular ejection fraction at diagnosis, its rate and time of recovery, and maternal outcome. This study helps to define the clinical profile of patients with pregnancy-associated cardiomyopathy diagnosed in the United States. Clinical presentation and outcome of patients with pregnancy-associated cardiomyopathy diagnosed early in pregnancy are similar to those of patients with traditional peripartum cardiomyopathy. These 2 conditions may represent a continuum of a spectrum of the same disease.
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                Author and article information

                Contributors
                Edward J. Lesnefsky: Role: Editor
                Journal
                Journal ID (nlm-ta): PLoS One
                Journal ID (iso-abbrev): PLoS ONE
                Journal ID (publisher-id): plos
                Journal ID (pmc): plosone
                Title: PLoS ONE
                Publisher: Public Library of Science (San Francisco, CA USA )
                ISSN (Electronic): 1932-6203
                Publication date (Electronic): 7 August 2015
                Publication date Collection: 2015
                Volume: 10
                Issue: 8
                Electronic Location Identifier: e0133466
                Affiliations
                [1 ]The Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
                [2 ]Department of Statistical Sciences, University of Cape Town, Cape Town, South Africa
                [3 ]Hatter Institute for Cardiovascular Research in Africa, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
                Virginia Commonwealth University, UNITED STATES
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Conceived and designed the experiments: BM NN. Performed the experiments: NN. Analyzed the data: FG MB NN KS BM. Contributed reagents/materials/analysis tools: FG MB. Wrote the paper: NN MB FG KS BM.

                [¤]

                Current address: College of Medicine, King Saud Bin Abdelaziz University of Medical Sciences, Riyadh, Kingdom of Saudi Arabia

                Article
                Publisher ID: PONE-D-14-17780
                DOI: 10.1371/journal.pone.0133466
                PMC ID: 4529210
                PubMed ID: 26252951
                SO-VID: fa14f15f-e49d-4bfd-9d75-4546b4fd4eec
                Copyright statement: Copyright @ 2015
                License:

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited

                History
                Date received : 28 April 2014
                Date accepted : 28 June 2015
                Page count
                Figures: 3, Tables: 3, Pages: 13
                Funding
                The authors of this article are funded in part by research grants from the Discovery Foundation(NBAN), Medical Research Council of South Africa( www.mrc.ac.za) (BMM), the National Research Foundation ( www.nrf.ac.za)(BMM, KS), and the Lily & Ernst Hausmann Research Trust (BMM). The funders played no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Subject: Research Article
                Custom metadata
                Data Availability Data are ethically restricted, and can be requested from the study pregancy-associated heart failure authors at the Department of Medicine, Old Groote Schuur Hospital, Groote Schuur Drive, Observatory 7925, Cape Town, South Africa. Tel: +27-21-406-6200; Fax: +27-21-448-6815; Email: bongani.mayosi@ 123456uct.ac.za .

                ScienceOpen disciplines: Uncategorized
                Data availability:
                ScienceOpen disciplines: Uncategorized

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