Peripartum Cardiomyopathy More Severe for Black Women

Megan Brooks

October 13, 2017

PHILADELPHIA, PA — African American women with peripartum cardiomyopathy (PPCM) fare markedly worse than non–African American women, a new study suggests[1].

Compared with non–African American women with PPCM, African American women with PPCM are diagnosed later postpartum, they present with more severe systolic dysfunction, their cardiac function worsens after diagnosis more often and recovers less frequently, and, when cardiac function does recover, it takes much longer to do so, findings of a case-control study indicate.

"While we know that African American women are at greater risk for PPCM, the disparity in disease diversity at presentation and the subsequent progression of the condition in this patient population was staggering," lead investigator Dr Olga Corazón Irizarry (University of Pennsylvania, Philadelphia) said in a news release[2].

The study was published online October 11, 2017 in JAMA Cardiology.

"Striking" Racial Differences

PPCM is a potentially life-threatening form of maternal systolic heart failure that occurs toward the end of pregnancy or soon after delivery in the absence of a clear cause or preexisting heart disease. PPCM disproportionately affects women of African ancestry, but few well-powered studies have looked at differences in disease severity and clinical outcomes.

Irizarry and colleagues compared the clinical characteristics, presentation, and outcomes of PPCM in 121 African American and 99 non–African American women (82 white, six Asian, four other, seven unknown). "To our knowledge, this retrospective review of 220 women represents the largest study of PPCM cases to date and in particular of African American women with PPCM," they note.

They report that African American women were diagnosed with PPCM at a younger age than non–African American women (mean age at diagnosis 27.6 vs 31.7 years, P<0.001).

They were also diagnosed later in the postpartum period. Forty-four of 88 non–African American women (50%) were diagnosed with PPCM within the first week after delivery, but the time of diagnosis was more spread out for African American women: 22 of 102 (22%) in the first week, 30 of 102 (29%) in the subsequent 3 weeks, and 33 of 102 (32%) in the subsequent 4 months.

Despite the younger age at diagnosis, African American women were more apt to present with low left ventricular ejection fraction (LVEF) (<30%, 57% vs 40%, P=0.03). They were also more likely to worsen after first diagnosis (35% vs 18%, P=0.02) and were twice as likely to fail to recover to an LVEF of 50% or higher (43% vs 24%, P=0.004).

And even among those who ultimately recovered, the time to recovery for African American women was at least twice as long as that for non–African American women (median time to recovery 265 days vs 126 days, P=0.02), despite a similar rate of treatment with beta-blockers and ACE inhibitors.

This racial differences are "striking," the investigators write.

They note that African American women with PPCM  were more likely to have chronic hypertension, but rates of gestational hypertension were high in both groups, which is in line with the "well-established strong" link between pregnancy-related hypertension and PPCM.

"This observation suggests that pathophysiologic differences between PPCM in African American and non–African American patients are unlikely to be caused by a different burden of gestational hypertension," they write.

It should be noted, the investigators say, that this was a retrospective review of medical records and not all demographic and clinical variables could be captured.

High-Risk Patients

Taken together, these findings suggest that African American women suffer from a pathophysiologically more severe form of PPCM or there are environmental factors that lead to more severe presentation and disease progression, Irizarry and colleagues conclude.

"Further work is needed to understand to what extent these differences stem from genetic or socioeconomic differences and how treatment of African American patients might be tailored to improve health outcomes," they add.

"At the very least," they say, African American women with PPCM, "need to be counseled differently from non–African American patients."

Dr Johann Bauersachs (Medical School Hannover, Germany) provides his insights on the study in an accompanying editorial[3].

He notes that not only is this the largest cohort of patients with PPCM to date, the investigators used stringent definitions for PPCM and excluded all patients with a possible alternate explanation for heart failure, such as a history of congenital heart disease, valvular heart disease, or receiving radiation treatment or chemotherapy.

Based on the findings, Bauersachs says African American women in the peripartum period "must be carefully evaluated, as well as all women with risk factors for PPCM, such as pregnancy-associated hypertension, twin pregnancy, and cesarean delivery. Special attention has to be devoted to high-risk patients with an ejection fraction of less than 35%, especially less than 25%, and/or cardiogenic shock. Given the worse outcomes for African American patients, they should be viewed as high-risk patients."

Finally, Bauersachs says, "Given the poor prognosis for African American women with PPCM, maximum therapeutic efforts, including the use of bromocriptine, should be considered."

The study had no commercial funding. The authors and Dr Bauersachs have disclosed no relevant financial relationships.

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