Home. Commonly asked questions About IPAC IPAC Center Contacts Recent PPCM Publications
Questions that PPCM patients may wish to ask their doctors:

1. What is my left ventricular ejection fraction (EF)? [Normal recovery range = 55 % or above (LV EF 50-54 % a "gray zone" for recovery--good for long life, but not quite good enough for future pregnancy).]

2. What is the size of my left ventricle (left ventricular end-diastolic dimension = EDD or left ventricular internal dimension in diastole = LViDd)? [Abnormal = over 2.7 cms per meter squared body surface area; that is about 4.5 cms for a woman 56 and 140 lbs. The size of the LV may be slower to return to normal than the LVEF. The shape, becoming more rounded rather than oblong, may also be changed, and sometimes becomes a permanent change. The best function is with the normal oblong shape, so that is what we desire to see ultimately.]

3. Do I need anticoagulants to prevent blood clots? [If EF below 30-35 %, in general anticoagulation is recommended to prevent clotting in the ventricle and pieces breaking off or emboli, resulting in a stroke or other complications.]

4. What was the level of my blood B-type Natriuretic Peptide (BNP)? [The blood BNP is a measure of hormone coming from the failing left ventricle and is usually elevated in heart failure. BNP may be elevated before clinical symptoms of heart failure appear. Each lab has its normal range. This may also help to follow progress or to be warned of relapse.]

5. Do I have any heart rhythm problems and do I need an implantable cardiovertor-defibrillator (ICD)? [Early in the course of PPCM if the EF remains below 30 % after 2 to 4 months, consideration should at least be given to having an ICD. Opinions vary about the need, timing and the level at which it is considered.] The goal is to prevent and/or deal with ventricular tachyarrhythmias. Beta-blockade treatment may also help in that area, and it is important to include B-B in early treatment, as soon as tolerated. It is also possible to wear an external pack (LifeVest) on a temporary basis while watching for improvement.]

6. Other than fluid pills (diuretics) does my treatment include an ACE-inhibitor after delivery (example: enalopril, lisinopril) or hydralazine + nitrates before delivery and a Beta-blocker (example: metoprolol long-acting, or carvedilol, or bisoprolol)? Combination use of ACE-Inhibitors after delivery or hydralazine + nitrates before delivery and Beta-blockers as tolerated with gradually upward titrated dosages provide the best combination treatment for a variety of reasons.   They work better in combination than either one alone.  The biggest side effect is low blood pressure, and that is why one starts low and builds up slowly. In the early stages, if the blood pressure is too low, it may not yet be safe to start both the beta-blocker and ACEI (or ARB if ACEI not tolerated). However as soon as it can be tolerated, it should be included since it also helps to avoid ventricular tachyarrhythmias.]  An ARB (angiotensin receptor blocker) can be substituted for ACEI, if the latter not tolerated.  An example of an ARB is losartan.

7. What is the best family planning method to use? [Subsequent pregnancy is not advisable until recovery of normal heart function. There is always some risk for relapse of heart failure with a subsequent pregnancy. A variety of effective hormonal or non-hormonal birth control methods are available--including 3-month to 5-year depot-hormone systems, low-dose oral contraceptive, IUD {ParaGard, the copper IUD, and Mirena, the levonorgestrel-releasing intrauterine system (LNG-IUS)},tubal ligation--all of which carry far less risk than to become pregnant again before full heart recovery.]

8. How long should my treatment continue? [In general basic treatment should continue for a minimum of 1 year after diagnosis. Dosages and combinations of medications can be gradually decreased during and after this time if tolerated. It has been demonstrated that recovered PPCM patients may safely go off heart failure meds and remain at normal heart function. WARNING: IF THERE IS A HISTORY OF SERIOUS RHYTHM PROBLEMS IT IS BETTER TO REMAIN ON BETA-BLOCKADE TREATMENT UNTIL SHOWN TO BE SAFE TO DISCONTINUE.]

9. Is my kidney function normal, and are my electrolytes normal? [Kidney function is affected by heart failure and the diuretic medications may lead to loss of potassium and magnesium. Blood tests will measure these levels.]

10. If my ACE-I and B-B medicines cause too much blood pressure lowering what can I do? [The key to minimize B.P.-lowering side effects is to increase very slowly and gradually( for example, increase of Coreg by only 3.25 mg twice a day) with the first increase taken at bed-time when one is lying down, so that less effect is felt. It''s almost always possible to increase the medications if more improvement is needed.]

11.How fast am I expected to improve? [Almost every treated PPCM patient improves. Rate of recovery varies with each patient. A treated patient is below average rate of healing if the LV EF does not improve to at least 20 % by two to 4 weeks after starting treatment or to 35-40 % by 3 to 4 months after beginning treatment. Those who don't reach those milestones should talk with their doctors about additional studies.

12. Am I a candidate for cardiac MRI (CMR)?   On CMR, early Gadolinium enhancement (EGE) helps to identify areas of inflammation; and late gadolinium enhancement (LGE) helps to identify areas of scarring and fibrosis. 

13. How do I know if I have recovered normal heart function? [Follow-up echocardiograms will indicate left ventricular ejection fraction in excess of 50 % (a better figure may be 55 % and above or "at least 55 %" when considering subsequent pregnancy) with recovery. Maintaining a normal LV EF after the phase-out of heart failure meds confirms actual recovery. A stress echocardiogram, either with exercise or dobutamine, helps to indicate if there is also normal contractile reserve, the best indicator that we presently have for complete healing.]

14. Have blood tests been done for viral infection? [What I want to see happen is for new PPCM patients to have that blood test for Igm and IgG antibodies against the viruses listed below at the time of diagnosis. And if IgM positive, then to go to the PCR blood testing. OR, if getting worse or failing to improve, to have endomyocardial biopsy with PCR testing on heart biopsy tissue for that and other myocarditis viruses(Coxsackievirus B, Adenovirus, Humanherpesvirus 6, Cytomegalovirus, E-B virus, Hepatitis C virus in addition to Parvovirus B19).  What is clearly emerging is that those with positive blood IgM antibodies to one of these viruses that cause inflammation in the heart may have positive viral particles in the blood when PCR testing is done. There are already reports of viral + in PCR testing of blood in PPCM, and more reports of viral + in endomyocardial biopsy tissue.

15. Do breastfeeding and the hormone, prolactin, play a role in PPCM? [RESPONSE: Currently, some important research is taking place on the role of prolactin in the cause of PPCM and pre-eclampsia. Right now, we can't say for sure. Hilfiker-Kleiner and Sliwa are advocates of lowering plasma prolactin postpartum by stopping breastfeeding, on the theory that it may lead to more cardiac stress and be metabolized to a harmful protein in some genetically-susceptible individuals. So far, several studies have not shown any outcome benefit at 6 or 12 months postpartum for those treated with bromocriptine compared to those with similar conventional treatment but no bromocriptine.  It is important to continue studies in this area, and time will tell.--JDF]

16.  What about future pregnancies?   See this topic continued on the tab, "?Future Pregnancy?".  

17.    What are the useful blood test "biomarkers" that should be done at the time of diagnosis?   Those that are useful for various purposes are:  serum B-type Natriuretic Peptide (BNP); serum sFLT1; and serum Placental Growth Factor (PlGF).   More detail is available on the IPAC and other reports.
  






Home.
Commonly asked questions
About IPAC
IPAC Center Contacts
Recent PPCM Publications
?Future Pregnancy?
Early Detection PPCM
Treatment PPCM, AHA Guidelines
Slide Show
 If you have any feedback on how we can make our new website better please do contact us. We would like to hear from you. 
Site Map