From the Guidelines
For acute on chronic dilated peripartum cardiomyopathy, a multi-drug regimen is typically required, prioritizing medications that improve cardiac function, reduce symptoms, and prevent complications while considering the unique aspects of peripartum status.
Medication Regimen
The treatment should be guided by the most recent and highest quality evidence, which suggests that the management of peripartum cardiomyopathy should follow the current guidelines for heart failure, with specific considerations during pregnancy 1.
- Start with furosemide 20-40 mg IV or PO daily to reduce fluid overload, as diuretics are crucial in managing fluid status, although they should be used sparingly to avoid decreased placental blood flow 1.
- Add metoprolol 12.5-25 mg PO twice daily to reduce heart rate and myocardial oxygen demand, as beta-blockers have not been shown to have teratogenic effects and are preferred for their beta-1 selectivity 1.
- If postpartum or not pregnant, initiate enalapril 2.5-5 mg PO twice daily to reduce afterload; however, during pregnancy, consider hydralazine as an alternative due to the contraindication of ACE inhibitors and ARBs because of serious renal and other fetal toxicity 1.
- For anticoagulation, use enoxaparin 1 mg/kg subcutaneously twice daily to prevent thromboembolism, especially in the first 6 to 8 weeks postpartum when hypercoagulability is most pronounced, and consider anticoagulation for women with severely depressed LVEF (<30%) in the setting of acute heart failure caused by peripartum cardiomyopathy 1.
- Consider adding digoxin 0.125-0.25 mg PO daily to improve contractility, although its use should be carefully monitored due to the potential for toxicity.
Monitoring and Adjustments
In severe cases of acute decompensation, inotropic support with dobutamine or milrinone may be necessary, and careful monitoring of vital signs, fluid status, and cardiac function is crucial 1.
- Adjust medication doses based on patient response and renal function.
- Be cautious with ACE inhibitors and ARBs during pregnancy due to fetal risks. The goal of treatment is to improve cardiac function, reduce symptoms, and prevent complications while considering the unique aspects of peripartum status, and this regimen addresses the key pathophysiological aspects of cardiomyopathy: reducing preload and afterload, improving contractility, and preventing thrombotic complications 1.
From the Research
Medications for Acute on Chronic Dilated Peripartum Cardiomyopathy (PPCM)
The treatment for acute on chronic dilated peripartum cardiomyopathy (PPCM) involves medications that are typically used for acute systolic heart failure, as well as some specific treatments. The following medications may be used:
- Neurohormonal antagonists, which are used in other forms of cardiomyopathy 2
- VKA (Vitamin K Antagonist) treatment, which may be discussed in cases where systolic function is less than 25% due to a higher risk of thrombus 3
- Bromocriptine, which can be initiated on a case-by-case basis 3
- β-blockers to control cardiac remodeling 4
- Thiazide diuretics to reduce preload 4
- Hydralazine and nitrates to reduce afterload 4
- Digoxin to increase inotropy 4 It's worth noting that the management of PPCM is largely limited to the same treatments used in other forms of cardiomyopathy, and no proven disease-specific therapies exist yet 2. However, research has identified potential disease-specific biomarkers and therapies, including those targeting unbalanced oxidative stress and the cleavage of the nursing hormone prolactin (PRL) into an angiostatic, pro-apoptotic, and pro-inflammatory 16 kDa-PRL fragment 5.
Treatment Approach
The treatment approach for PPCM typically involves an interdisciplinary approach in a perinatal center with consequent follow-up of the patients for risk stratification, including echocardiography 6. The severity of the disease requires careful management, and the treatment is often similar to that of dilated cardiomyopathy (DCM) and acute cardiac failure 6.