Sunday, 29 August 2010

Abstract

Background: Risk factors for development of peripartum cardiomyopathy (PPCM) are poorly understood. Reports on outcome of PPCM are conflicting, with variable mortality rates reported by different authors. Purpose: To define the risk factors for development of PPCM and the predictors of survival outcome in PPCM. Methods: Retrospective analysis of the medical records of patients diagnosed with PPCM at the Groote Schuur Hospital Cardiac Clinic, South Africa, between February 1 1996 and December 31 2009. Diagnosis of PPCM was based on development of heart failure between the last month of pregnancy and fifth postpartum month in women without pre-existing heart disease, or any other identifiable cause of heart failure, including pregnancy-induced hypertension. Patients also needed to fulfill established echocardiographic criteria for diagnosis. Measurements from clinical assessment, chest radiography, electrocardiography, twodimensional and Doppler colour-flow echocardiography and cardiac catheterisation (where available) were reviewed. Results: There were 30 PPCM patients studied, with a mean age of 31.45±7.48 years. Ethnicity, gravidity, parity, and unemployment were not associated with increased risk of developing PPCM in this study. However, twin pregnancy emerged as a significant risk factor for disease development in PPCM (p<0.001). The median follow-up was 4.33 years (range 0.16 - 13.8). During the study period 5 (16.6%) subjects died and 24 (80%) patients remained in chronic heart failure. Complications included intra-cardiac thrombus formation (16.7%), atrial fibrillation (10.0%), stroke (6.7%), and pulmonary hypertension (13.3%). One patient had cardiac resynchronisation therapy and another patient had orthotopic heart transplantation. Predictors of increased mortality in the time-to-event analysis included twin pregnancy (p<0.001), heart rate greater than 120 bpm at first clinic visit (p=0.017), presence of atrial fibrillation (p=0.023), use of warfarin (p=0.019), and NYHA functional class III and IV symptoms at last visit (p=0.005). On multivariate logistic regression analysis only NYHA functional class III/IV status at last visit was a significant predictor of mortality (OR 3.107 [1.329 - 11.981], p=0.047). Conclusions: PPCM affects young women, with significant morbidity and mortality. Mortality in this study is lower than in many other previously reported studies. Twin pregnancy is a risk factor for development of PPCM. The NYHA functional class emerges as a powerful predictor of mortality in this study.