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It is important for clinicians to be alert to the possibility of subclinical, latent, or incubating peripartum cardiomyopathy (PPCM).  Numerous reports have substantiated that early diagnosis and subsequent treatment may result in reduced morbidity and mortality.   For this reason we have become very sensitive to the early symptoms of heart failure in women during their last month of pregnancy and within 5 months postpartum.  We teach all peripartum women to come to the clinics and hospitals if they have these signs that could be associated with left ventricular dysfunction:

 

1)     Noticeable dyspnea on exertion or shortness of breath at rest,

2)     Persistent cough that fails to clear,

3)     Noticeable and increasing swelling of the legs,

4)     Inability to lie flat to sleep, and/or sudden awakening at night with shortness of breath, and

5)     Other symptoms including palpitations (irregular pulse) and feeling of faintness or light-headedness.

 

These are all symptoms that merit medical consultation and consideration for doing an echocardiogram, the definitive test that can identify a dilated cardiomyopathy.  Medical history and physical exam alone may not alert the clinician to early left ventricular systolic dysfunction.

There is no clear correlation between mild left ventricular systolic function impairment and clinical symptoms.  Noticeable dyspnea on exertion or at rest varies considerably from patient to patient with similar mild reductions in left ventricular ejection fraction.  Therefore, it is understandable that the diagnosis of PPCM may be delayed or even totally missed unless there is a high level of suspicion, and additional assessments are made.  

There are at least two blood tests may help in early detection of left ventricular dysfunction:

1)     B-type Natriuretic Peptide (BNP), indicating left ventricular stress,  and

2)     High sensitivity C-Reactive Protein (hs-CRP or CRP) associated with an inflammatory cardiomyopathy, which is often found with PPCM.

In addition, many medical centers now have available an imaging tool to help confirm this:  Cardiac magnetic resonance imaging (CMR), with gadolinium enhancement.

 

Why does this process lead to heart failure?  Gradual loss of functioning cardiomyocytes exceeding a critical mass leads to left ventricular dilatation and left ventricular systolic dysfunction.  Time interval between the initiation of this process and the development of clinically detectable heart failure is variable and unknown.   The interval may be timed in hours, days, weeks or months.   An increased sensitivity to the possibility that this type of heart failure could affect young mothers with a previously healthy heart will help to assure both survival and full recovery.

 

James D. Fett, MD

8 January 2012

 


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