peripartum cardiomyopathy
DESCRIPTION
PERIPARTUM CARDIOMYOPATHY. DR.T.NEELAMBUJAN,M.D.,DNB(CARDIO)., CONSULTANT CARDIOLOGIST & INTERVENTIONALIST SUNDARAM ARULRHAJ HOSPITAL TUTICORIN. DYSPNEA – POST PARTUM. 35/F – DOE ; 3 WKS AFTER DELIVERY HTN DURING PREGNANCY NO CARDIOVASCULAR DISEASE - PowerPoint PPT PresentationTRANSCRIPT
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PERIPARTUM CARDIOMYOPATHY
DR.T.NEELAMBUJAN,M.D.,DNB(CARDIO).,CONSULTANT CARDIOLOGIST & INTERVENTIONALIST
SUNDARAM ARULRHAJ HOSPITALTUTICORIN
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DYSPNEA – POST PARTUM
35/F – DOE ; 3 WKS AFTER DELIVERY HTN DURING PREGNANCY NO CARDIOVASCULAR DISEASE O/E : B.P 110/70 mm Hg ; PR 105 /min LOW
VOL PERIPHERAL PULSES WELL FELT RR 28/min. JVP 10 cm ;PEDAL EDEMA Grade II PANSYSTOLIC MURMUR LVS3 + BILATERAL RALES
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LIKELY CAUSES?
PERIPARTUM CMP
PULMONARY EMBOLISM
AORTIC DISSECTION
ACUTE MI
ANAEMIA WITH HF
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ECHO
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PERIPARTUM CARDIOMYOPATHY
DEMAKIS et al- 1971 NAMED DCM WITH SIGNS OF HF IN THE
LAST MONTH OF PREGNANCY OR WITHIN
5 MONTHS OF DELIVERY
INCIDENCE VARIES
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TIMING OF DIAGNOSIS
DX. REQUIRES BEING IN THE LAST MONTH OF PREGNANCY
IF EARLIER, CONSIDER OTHER HEART DISEASE (ISCHEMIC, VALVULAR, OR MYOPATHIC)
2ND TRIMESTER BURDEN
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WHAT CAUSES IT?
• OLDEST THEORY
• ENDOMYOCARDIAL BIOPSY
• VARIABLE PREVALENCE
MYOCARDITIS
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PATHOLOGIC IMMUNE RESPONSE VIRAL INFECTION & PATHOLOGIC IMMUNE
RESPONSE AGAINST VIRAL ANTIGENS
CROSS REACTS WITH NATIVE CARDIAC TISSUE PROTEINS
PARVOVIRUS B19; HUMAN HERPES VIRUS 6; EBV; CMV
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CHIMERISM
CELLS FROM FETUS COLONIZE IN MOTHER PROVOKING IMMUNE RESPONSE
AUTOANTIBODIES AGAINST CARDIAC TISSUE PROTEINS IN HIGH TITRES APOPTOSIS
APOPTOSIS OF CARDIAC MYOCYTES
ROLE OF Fas and Fas LIGAND
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ROLE OF PROLACTIN
• CARDIOMYOCYTE DELETION OF stat3
• ENHANCED CARDIAC CATHEPSIN D
• PROTEOLYTIC CLEVAGE OF PROLACTIN INTO 16KDa PRL FRAGMENT
• 16KDa PRL FRAGMENT- PROINFLAMMATORY,
PROAPOPTOTIC & ANTIANGIOGENIC
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OTHER POSSIBLE FACTORS
SELENIUM DEFICIENCY RELAXIN CARDIAC DYSTROPHIN IMMATURE DENDRITIC CELLS CARDIAC NO SYNTHASE HARMONE- PROGEST,PRL,OESTROGEN HAEMODYNAMIC STRESS OF
PREGNANCY FAMILIAL
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WHO IS AT RISK?
●AGE >30 YEARS ●MULTIPARITY●MULTIFETAL PREGNANCY●GESTATIONAL HTN●LONG TERM TOCOLYTIC Rx
●RACIAL●COCAINE ABUSE
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CLINICAL PRESENTATION
SYMPTOMSPNDDOECOUGHORTHOPNEACHEST PAINABD DISCOMFORTPALPITATIONTHROMBOEMBOLIS
MHAEMOPTYSISSCD
SIGNSCARDIOMEGALYGALLOP RHYTHMEDEMAMURMUR
UNEXPLAINED SYMPTOMS
HEIGHTENED SUSPICION
LATENT CMP
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ECHOCARDIOGRAM
• SPHERICAL LV• MITRAL AND
TRICUSPID REGURGITATION
• LEFT ATRIAL ENLARGEMENT
• EF <45%
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LABORATORY EVALUATION
HB
RENAL PARAMETERS
ELECTROLYTES & CALCIUM
TSH
BNP LEVELS
TROPONIN LEVELS
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ECG
• SINUS TACHYCARDIA
• NONSPECIFIC ST CHANGES
• LVH
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CHEST X-RAY
• PULMONARY EDEMA
• VENOUS CONGESTION
• CARDIOMEGALY
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CARDIAC MRI
♠ DELAYED CONTRAST ENCHANCEMENT (GADOLINIUM)
♠ CHARACTERIZE MYOCARDIUM & DIFFERENTIATE TYPE OF MYOCYTE NECROSIS
♠ GUIDE BIOPSY
♠ ASSESS LV FUNCTION
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HEART FAILURE Rx – PREGNANCY
♣ WELFARE OF FETUS & MOTHER♣ CO-ORDINATED MANAGEMENT♣ FETAL HEART MONITORING-
ADVISABLE♣ ACEI & ARBs -CONTRAINDICATED♣ DIG,BB,NITRATES & HYDRALAZINE-
SAFE♣ LOOP DIURETICS-CAUTIOUS USE♣ ELECTIVE LSCS-MOST CASES
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HEART FAILURE Rx- POSTPARTUM
♥ IDENTICAL TO NONPREG WITH DCM
♥ DIURETICS – SYMPTOM RELIEF
♥ DIGOXIN – REDUCES HOSPITALISATION
♥ ACEI & ARBs – MAXIMUM DOSE
♥ BB-CARVEDILOL & METAPROLOL
♥ HOW LONG TO TREAT?
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ANTICOAGULATION
► RISK OF THROMBOEMBOLISM HIGH
► ARTERIAL,VENOUS & CARDIAC
► WHO SHOULD RECEIVE ? SEVERE LV DYSFUNCTION DOCUEMENTED LV CLOT H/O SYSTEMIC EMBOLISM AF
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WARFARIN & HEPARIN
☻ WARFARIN SAFE AFTER FIRST TRIMESTER
☻ SWITCH TO UFH FOR PLANNED DELIVERY
☻ UNPLANNED DELIVERY ON WARF-LSCS
☻ MONITOR PT/INR VALUES
☻ ROLE OF DABIGATRAN
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NEWER TREATMENT
IV IMMUNOGLOBULINS IMMUNOSUPPRESSIVE BROMOCRIPTINE MONOCLONAL ANTIBODIES INTERFERON BETA THERAPEUTIC APHERESIS NONSPECIFIC IMMUNOADSORPTION
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IABP
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ECMO
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NATURAL COURSE
♦ BETTER SURVIVAL RATES
♦ 94% SURVIVAL AT 5 YEARS
♦ 54% RECOVERED NORMAL LV FUNCTION ( Elkayam et al )
♦ LV FUNCTION RECOVERS > 6 MONTHS
♦ RECOVERY MORE LIKELY -LVEF > 30%
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CRT
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ARTIFICIAL HEART CARDIAC TRANSPLANT
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POOR PROGNOSTIC FACTORS♪ HIGH TROPONIN T LEVELS
♪ QRS DURATION > 120 ms
♪ LVEF < 30%
♪ LVIDs > 5.5 cms
♪ FS > 20%
♪ LV THROMBUS
♪ RACE
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RISK OF RELAPSE?♥ LV FUNCTION COMPLETE RECOVERY- PREG NOT CONTRAINDICATED ( LOW
RISK )
♥ LV FUNCTION PARTIAL RECOVERY-DSE
♥ DSE NORMAL-PREG NOT CONTRAINDICATED
♥ DSE ABNORMAL-PREG NOT RECOMMENDED
♥ LV FUNCTION NOT RECOVERED-PREGNANCY CONTRAINDICATED (HIGH RISK)
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POORLY UNDERSTOOD DISEASE
HEIGHTENED SUSPICION FOR EARLY DIAGNOSIS
AGGRESSIVE ACUTE MANAGEMENT
RELAPSE- ACHILLES HEEL
HOPEFUL OPTIONS FOR CHRONIC HF
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THANK YOU