Risk stratification of women with peripartum cardiomyopathy at initial presentation: A dobutamine stress echocardiography study

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Objectives

We sought to determine the prognostic use of inotropic contractile reserve on risk stratification and prognostication of women with peripartum cardiomyopathy.

Background

Peripartum cardiomyopathy is a rare disorder effecting women in their prime years of life. There appears to be an initial high-risk period with 25% to 50% of women dying within the first 3 months postpartum. Early risk stratification and prognostication are, thus, crucial. However, only limited data are available.

Methods

In all, 7 women (mean age 31.8 years) with peripartum cardiomyopathy and severe left ventricular (LV) dysfunction (mean LV ejection fraction [LVEF] 25.3 ± 9.5%) were studied. Of these, 6 underwent dobutamine stress echocardiography at baseline and a follow-up resting echocardiogram at a mean of 4.7 ± 0.9 months after initial presentation. Resting and peak inotropic contractile reserve, and follow-up LVEF, were computed.

Results

The mean LVEF improved significantly from baseline (25.3 ± 9.5%) to maximal inotropic contractile reserve (53.8 ± 12.6%) (P = .0004) and at follow-up (53.0 ± 16.4%) (P = .006). Importantly, LVEF at maximal inotropic contractile reserve and at follow-up (5.6 months) did not differ significantly (P = .5). The mean LVEF at maximal inotropic contractile reserve correlated well with the follow-up (LVEF R = 0.79). However, the baseline LVEF did not correlate with follow-up LVEF (P = not significant).

Conclusions

In patients presenting with peripartum cardiomyopathy, inotropic contractile reserve during dobutamine stress echocardiography accurately correlates with subsequent recovery of LV function and confers a benign prognosis.

Section snippets

Patient selection

Peripartum cardiomyopathy was diagnosed in 7 women between July 1996 and October 1997 at our institution. The following criteria were used for the diagnosis of peripartum cardiomyopathy: the presence of LV dysfunction (LV ejection fraction [LVEF] < 40%) in the last trimester of pregnancy or within 5 months of delivery; absence of underlying heart or valvular disease before the last trimester of pregnancy; absence of substance abuse; chronic uncontrolled hypertension; chronic systemic disease;

Results

In all, 6 women given the diagnosis of peripartum cardiomyopathy and severe resting LV dysfunction were studied. Their mean age was 31.8 years and mean LVEF was 25.3 ± 9.5% (14%-36%). The echocardiographic parameters at baseline, during dobutamine infusion demonstrating maximal inotropic contractile reserve, and at follow-up are listed in Table 1.

The peak dose of dobutamine infusion was 27 μg/kg/min (15-50 μg/kg/min). All 6 women demonstrated marked inotropic contractile reserve at peak dose of

Discussion

Although peripartum cardiomyopathy is a relatively rare disease, it can have devastating consequences with high mortality (18%-56%).6, 7 The prognostic value of a variety of clinical and echocardiographic characteristics in this disease has been studied.

Demakis et al8 studied 27 patients of which 13 had persistent cardiomegaly at the end of 6 months. The group of patients with residual cardiomegaly had a very high mortality (85%) at 4.7 years. A number of other studies also revealed LV size and

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Current author affiliations: Brigham and Women's Hospital, Boston, Massachusetts (S.D.); St Luke's-Roosevelt Hospital Center, New York, New York (S.Z., P.H., F.A.C.); Columbia University College of Physicians & Surgeons, New York, New York (S.B., J.-F.R.); University of Pennsylvania Medical Center, Philadelphia, Pennsylvania (S.B., J.-F.R.); and the Heart and Vascular Center of Florida, Cleveland Clinic, Naples, Florida. (K.G.)

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