What are the medications for acute decompensated heart failure (HF) in chronic dilated cardiomyopathy (DCM) of peripartum cardiomyopathy (PPCM)?

From the Guidelines

For acute decompensated peripartum cardiomyopathy, the most effective management strategy includes the initiation of intravenous furosemide, nitroglycerin, and dobutamine as needed, followed by guideline-directed medical therapy with ACE inhibitors, beta blockers, and aldosterone antagonists postpartum, as recommended by the most recent guidelines 1.

Initial Management

The initial management of acute decompensated peripartum cardiomyopathy involves the use of intravenous diuretics, such as furosemide, to reduce congestion and volume overload, as well as intravenous nitrate, like nitroglycerine, for patients with a systolic blood pressure ≥110 mmHg 1. Inotropic agents, including dobutamine and levosimendan, should be considered in patients with a low output state or persistent congestion despite vasodilators and diuretics.

Ongoing Management

For ongoing management, the initiation of guideline-directed medical therapy (GDMT) is crucial. This includes the use of ACE inhibitors, such as enalapril, beta blockers, like metoprolol succinate, and aldosterone antagonists, such as spironolactone, postpartum 1. These medications have been shown to improve cardiac function and survival in patients with heart failure.

Anticoagulation and Bromocriptine

Consideration of anticoagulation with enoxaparin is recommended due to the increased risk of thromboembolism in peripartum cardiomyopathy 1. The use of bromocriptine, a novel disease-specific treatment for PPCM, may be beneficial in patients with acute onset of PPCM and LVEF <25% or cardiogenic shock, but its efficacy and safety remain uncertain and require further study 1.

Monitoring and Adjustments

Close monitoring of blood pressure, heart rate, and volume status is necessary, with adjustments to the management strategy as appropriate to avoid hypotension and placental hypoperfusion. The peripartum context necessitates close monitoring and potential adjustments to standard heart failure protocols.

Key Points

• Intravenous furosemide, nitroglycerin, and dobutamine as needed for initial management
• GDMT with ACE inhibitors, beta blockers, and aldosterone antagonists postpartum
• Consideration of anticoagulation with enoxaparin
• Potential use of bromocriptine in select patients
• Close monitoring and adjustments to management strategy as necessary

From the FDA Drug Label

Milrinone Lactate Injection is indicated for the short-term intravenous treatment of patients with acute decompensated heart failure. The medication for acute decompensated heart failure (HF) in chronic dilated cardiomyopathy (DCM) of peripartum cardiomyopathy (PPCM) is milrinone (IV), as it is indicated for the short-term intravenous treatment of patients with acute decompensated heart failure 2.

• Key points:
  • Milrinone lactate is a positive inotrope and vasodilator.
  • It is used for the short-term intravenous treatment of acute decompensated heart failure.
  • The majority of experience with intravenous milrinone lactate has been in patients receiving digoxin and diuretics 2.

From the Research

Medications for Acute Decompensated Heart Failure in Peripartum Cardiomyopathy

The medications used to treat acute decompensated heart failure in peripartum cardiomyopathy (PPCM) are similar to those used in other forms of heart failure. The following medications may be used:

• Diuretics to reduce fluid overload and alleviate symptoms such as shortness of breath and edema 3
• Angiotensin converting enzyme inhibitors (ACEi) to reduce afterload and improve cardiac function, although they are contraindicated before delivery 3, 4
• Beta-blockers to reduce heart rate and improve cardiac function 4
• Anticoagulation therapy to prevent thromboembolic complications, which are common in PPCM 3

Additional Treatment Options

In severe cases of PPCM, additional treatment options may be considered, including:

• Left ventricular assist device (LVAD) therapy, which can be used as a bridge to heart transplantation or to support the heart until it recovers 5
• Immunosuppressive treatment, which may be used in cases of fulminant or highly inflammatory PPCM, although its efficacy is still controversial 3
• Bromocriptin, a prolactin secretion inhibitor, which has shown promising results in reducing morbidity and mortality in PPCM, but requires further study 3

Important Considerations

It is essential to note that the treatment of PPCM should be individualized and guided by the severity of the disease and the patient's response to therapy. Close monitoring and follow-up are crucial to ensure optimal outcomes 6, 3.