Peripartum cardiomyopathy: Challenges and perspectives

Transcription

1 Prof. Petar M. Seferović, MD, PhD, FESC, FESC Board member, Heart Failure Association of the ESC Peripartum cardiomyopathy: Challenges and perspectives Director, Department of Cardiology, Clinical Center of Serbia Belgrade, Serbia

2 PPCM is usually presenting with HF secondary to LV systolic dysfunction (EF less than 45%, LV may not be dilated) Appears at the end of pergnancy or in the months following delivery. Diagnosis of exclusion

3 Incidence of peripartum CMP Data from European countries currently not available Gunderson et al., 2011, USA : 2066 Population based Hasan et al., 2010, Pakistan : 837 Case series (single institution) PPCM defined as: HF symptoms that appear one month before to 5 months after delivery. National Heart Lung and Blood Institute (2000)

4 Pathophysiology of PPCM 1.Cardiac tissue microenvironment: impaired metabolism of cardiomyocytes disrupted microcirculation 2. SYSTEMIC FINDINGS: Inflammation elevated levels of sfas/apo-1, C-reactive protein, interferon gamma (INFγ) and IL-6 Autoimmune processes circulating auto-antibodies to all types of cardiac tissue, antibodies causal or secondary to cardiac damage?

5 Pathophysiological basis for cardiomyocyte malfunction in PPCM: oxidative stress and prolactin Oxidative stress activation of cathepsin D (acd) in cardiomyocytes cleavege of prolactin via cathepsin D creation of 16 kda subform of prolactin 16 kda subform of prolactin is anti-angiogenic, pro-apoptotic and proinflammatory Yamac H et al., Prolactin: a new therapeutic target in peripartum cardiomyopathy. Heart Sep;96(17): Epub 2010 Jul 23.

6 Risk factors for development of peripartum CMP Blauwet LA, Cooper LT. Diagnosis and management of peripartum cardiomyopathy. Heart Dec;97(23):

7 Recent scientific evidence for genetic susceptibility to peripartum CMP A subset of PPCM is an initial manifestation of familial DCM (van Spaendonck-Zwarts KY, Circulation 2010) mutation in the gene encoding cardiac troponin C (TNNC1) African Americans have higher risk of PPCM, and Hispanics have lower risk than average population Position statement of HFA working group on PPCM...general genetic testing is not recomended as a routine but is currently being done as part of research projects. From the position statement of ESC HFA working group on peripartum cardiomyopathy, Eur J Heart Fail ,

8 Early signs and symptoms Peripheral edema Dyspnoea on exertion Orthopnoea Paroxysmal nocturnal dyspnoea Persistant cough these symptoms mimic normal physiological findings of pregnancy From the position statement of ESC HFA working group on peripartum cardiomyopathy, Eur J Heart Fail ,

9 Onset of symptoms The majority of patients (78%) experiences signs of heart failure 4 months after delivery 9% of patients present in the last month of pregnancy 13% present either prior to 1 month before delivery, or more than 4 months postpartum Complications 1. Left ventricular thrombosis in patients with severely impaired systolic function (EF<35%) 2. Peripheral embolic episodes cerebral, coronary, mesenteric, pulmonary Peripartum Cardiomyopathy with left ventricular thrombus. Courtesy of K. Sliwa, Soweto Cardiovascular Research Unit.

10 Early diagnostic algorithm Breathless woman towards the end of pregnancy/early post partum ECG abnormalities ST and T wave abnormalities in 96%, voltage criteria consistent with LV hypertrophy in 66%. Any abnormalities ECG OR natriuretic peptides AND echocardiography All normal B-type natriuretic peptide increased plasma levels in virtually all patients Further cardiology diagnostics Consider noncardiovascular causes From the position statement of ESC HFA working group on peripartum cardiomyopathy, Eur J Heart Fail ,

11 Cardiac imaging in PPCM patients 1. Echocardiography: diagnosis: LV dilatation, diminished systolic function (LVEF <45%) prognosis: LVEDD >60mm and/or LVEF <30% predicts poor recovery of LV function rulling out LV thrombus 2. MRI: more accurate measurements of LV volumes and function, higher sensitivity in diagnosing LV thrombus; measurement of late enhancement following administration of gadolinium to exclude myocardial inflammation Echocardiography repeated at discharge, 6 weeks, 6 months, and anually to evaluate the efficacy of medical treatment

12 Therapy options for acute heart failure in peripartum cardiomyopathy 1. Emergency medication: administration of oxygen + i.v. diuretics if congestion is present + i.v. nitrate if SBP >110mmHg 2. i.v. inotropics and/or intra-aortic balloon pump counterpulsation 3. Implantation of left ventricular assist device, at least as bridge to transplantation 4. Up to 11% of patients with PPCM undergo heart transplantation From the position statement of ESC HFA working group on peripartum cardiomyopathy, Eur J Heart Fail ,

13 Medical therapy for stable heart failure in peripartum cardiomyopathy 1. If heart failure symptoms begin after delivery the ESC HFA guidelines apply 2. If heart failure onsets prior to delivery, following restrictions apply: a. ACE inhibitors and ARBs are contraindicated, instead hydralazine and long-acting nitrates should be used b. Beta-1 selective blockers are preferred (generally beta-blockers are not contraindicated) c. Warfarin is contraindicated, should be replaced by unfractioned or low-molecular weight heparin d. Diurectics should be used with caution, spirinolactone and eplerenone should be avoided From the position statement of ESC HFA working group on peripartum cardiomyopathy, Eur J Heart Fail ,

14 Indications for cardiac resynchronization therapy (CRT) and implantation of defibrillators (ICD) In PPCM patients with severely impaired systolic function 6 months after onset of symptoms, despite optimal therapy, ICD is advisable (along with CRT if patient has NYHA III or IV and QRS duration > 120ms) From the position statement of ESC HFA working group on peripartum cardiomyopathy, Eur J Heart Fail ,

15 Novel therapies: PPCM targeted at its fundaments Effects of biologically active form of prolactin (16 kda) in the cardiac microenvironment is found to be associated with cardiomyocyte malfunction Oxidative stress Cathepsin D Bromocriptine inhibits secretion of prolactine and detrimental 16 kda subform is not generated Biologically active form of prolactin Lok SI et al. Peripartum cardiomyopathy: the need for a national database. Neth Heart J Mar;19(3): Epub 2011Jan 27.

16 Bromocriptin in PPCM: Clinical results Dosing: 2.5mg twice daily for 2 weeks, than 2.5mg daily for 6 weeks Systolic function: change in LVEF in the bromocriptine group from 27% to 58% at 6 months vs. 27% to 36% in the control group Thrombo-embolic complications (occurence of MI has been reported) in patients taking bromocriptine anti-coagulation therapy is required Sliwa K. Evaluation of bromocriptine in the treatment of acute severe peripartum cardiomyopathy: a proof-of-concept pilot study. Circulation 2010;121:

17 Delivery, breastfeeding and subsequent pregnancies 1. Timing: Urgent delivery is recomended if haemodynamic instability is persistent 2. Mode: If mechanical support or i.v. inotropics are required Caesarean section is preferred Continuous spinal anaesthesia, and combined spinal and epidural anaesthesia are recommended 3. Breastfeeding not recommended in PPCM patients due to described detrimental effects of prolactin 4. Subsequent pregnancies - contraindicated, if LVEF <25% at diagnosis, or subsequently not normalized From the position statement of ESC HFA working group on peripartum cardiomyopathy, Eur J Heart Fail ,

18 Prognosis of PPCM varies geographically? Turkey Single center study, mortality rate 30% at 4 years Single center studies, mortality rate 14-16% at 6 months South Africa Population-based study from South Africa show mortality rates of 10% at 6 months and 28% at 2 years Possible independent mortality predictors: NYHA class, LVEF, QRS duration, late onset of symptoms

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20 Study Group on Peripartum Cardiomyopathy Prof. K. Sliwa (Cape Town, South Africa) Prof. B. Pieske (Graz, AT) D Hilfiker-Kleiner (Hannover, DE) J McMurray (Glasgow, GB) A Mebazaa (Paris, FR) M Petrie (Glasgow, GB) V Regitz-Zagrosek (Berlin, DE) M Schaufelberger (Gothenburg, SE) P Seferovic (Belgrade, RS) A Shah (London, GB) L Tavazzi (Cotignola, IT) D van Veldhuisen (Groningen, NL) K van Spaendonck-Zwart (Haren, NL) U Elkayam (Los Angeles, US) F Mouquet (Lille, FR) Z Papp (Debrecen, HU) Aims To establish a platform where current knowledge on peripartum cardiomyopathy based on experimental and clinical studies is summarized and regularly up-dated. To raise awareness of this uncommon but devastating problem by promoting sessions at congresses and publishing articles. To coordinate the collection and analysis of data internationally for better understanding of the condition. To meet regularly to discuss and update management strategies with a focus on novel diagnostic and therapeutic approaches. Provide information and contact addresses on our webpage for physicians and patients concerned about PPCM. Registry: in planning

21 ESC HFA PPCM Registry: Started online April 2nd 2012 N=1000 patients European Society of Cardiology Members Countries The questionnaire will be accessed through the Heart Failure Association (HFA) of the ESC website, or directly by using a web address which will bring specialists to the log-in page of the questionnaire. Criteria: Peripartum stage Signs and/or symptoms of heart failure Ejection fraction <45%

22 EURObservational Research Programme Characteristics - Screen 1

23 EURObservational Research Programme Peripartum cardiomyopathy Clinical data in the registry 1.2. Clinical history 1.3. Current pregnancy 1.4. Previous pregnancy 4.1. Chronic home medications 4.2. Anticoagulants during curent pregnancy 5.2. Physical signs 5.3. Investigations/procedures during hospitalisations/index Visit 5.4. Chemistry 5.5. Treatment 5.6. Vital status 8.1. Status 1 months post inclusion

24 Creating awareness for the condition and the registry: Website with information in several languages for physicians and patients