From the Guidelines
The treatment of peripartum cardiomyopathy (PPCM) involves standard heart failure management with some specific considerations for pregnant and postpartum women, including guideline-directed medical therapy with ACE inhibitors, ARBs, β-blockers, and aldosterone antagonists, as well as the potential use of bromocriptine in select cases. The management of PPCM should be guided by the most recent and highest quality evidence, which emphasizes the importance of a multidisciplinary team approach, including cardiologists, high-risk obstetricians, and perinatologists 1. Initial therapy for PPCM includes:
- ACE inhibitors (such as enalapril 2.5-20 mg twice daily) or ARBs (such as losartan 25-100 mg daily) for patients who are postpartum, but these are contraindicated during pregnancy
- Beta-blockers (metoprolol succinate 12.5-200 mg daily or carvedilol 3.125-25 mg twice daily) should be initiated at low doses and gradually increased
- Diuretics like furosemide (20-80 mg daily or twice daily) help manage fluid overload
- During pregnancy, hydralazine (10-75 mg three times daily) combined with nitrates can replace ACE inhibitors/ARBs
- Anticoagulation with low molecular weight heparin or warfarin is recommended for patients with severely reduced ejection fraction (EF <35%) to prevent thromboembolism
- Bromocriptine (2.5 mg twice daily for 2 weeks, followed by 2.5 mg daily for 6 weeks) may be considered in select cases to inhibit prolactin, particularly in women with LVEF <25% or cardiogenic shock, as suggested by the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1. For patients with persistent severe heart failure despite optimal medical therapy, advanced options include implantable cardioverter-defibrillators, cardiac resynchronization therapy, or heart transplantation. Close monitoring is essential as many women show significant improvement in cardiac function within 3-6 months, though some may have persistent dysfunction requiring lifelong therapy. The duration of standard HF medications in patients with PPCM should be indefinite when LV function fails to normalize, and patients with PPCM whose ventricular function does not normalize after pregnancy should be counseled against a subsequent pregnancy due to the significant risk of morbidity and mortality 1.
From the Research
Treatment Options for Peripartum Cardiomyopathy (PPCM)
The treatment for PPCM typically involves a combination of conventional pharmacologic heart failure therapies and targeted therapies. Some of the key treatment options include:
- Conventional pharmacologic therapies such as diuretics, angiotensin-converting enzyme inhibitors, vasodilators, digoxin, β-blockers, and anticoagulants 2, 3
- Targeted therapies such as bromocriptine, which has been shown to improve left ventricular systolic function and patient-oriented clinical end points 4, 5, 6
- Pentoxifylline, a nonselective phosphodiesterase inhibitor, which has also been shown to improve left ventricular systolic function and patient-oriented clinical end points 4, 3
- Mechanical support and transplantation may be necessary in severe cases 2, 3
Management of PPCM
The management of PPCM typically involves a multidisciplinary team with experience in high-risk pregnancy and the treatment of heart failure 5. Women with PPCM should be managed with standard treatments for heart failure therapy, with the exception of avoiding ACE inhibitors and ARBs while pregnant 5. Frequent prescription of beta-blocker, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, and bromocriptine/cabergoline have been associated with significantly lower all-cause mortality and better left ventricular recovery 6.
Recovery and Outcomes
The rate of recovery of ventricular function in PPCM is higher than in other forms of dilated cardiomyopathy, with approximately 44.1% of patients recovering their left ventricular function within 6 months and 58.7% within 12 months 6. However, subsequent pregnancies are almost always associated with recurrence of left ventricular systolic dysfunction 2. All-cause mortality rates for PPCM have been reported to be around 8.0% at 6 months and 9.8% at 12 months, with significant global differences in outcomes 6.