American Journal of Emergency Medicine xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Correspondence
Peripartum cardiomyopathy in the ED To the Editor, We read with interest the review article recently published by McGregor et al [1] entitled “The pregnant heart: cardiac emergencies during pregnancy.” However, we have some concerns about the definition of peripartum cardiomyopathy (PPCM), which is a rare obstetric emergency. Presentation of PPCM in the emergency department is similar to that of patients presenting with heart failure due to other causes [2]. Diagnosis of PPCM is often missed or delayed because most of the signs and symptoms of normal pregnancy are similar to those of heart failure [2]. Peripartum cardiomyopathy should be differentiated from other forms of cardiomyopathy, heart failure, pulmonary thromboembolism, severe eclampsia, pneumonia, myocardial infarction, idiopathic dilated cardiomyopathy, and valvular heart disease. Peripartum cardiomyopathy has a number of definitions. McGregor et al defined PPCM as “left ventricle systolic dysfunction during the last month of pregnancy and the first 5 months after delivery.” However, the restriction of the time frame to last month of pregnancy or first 5 months postpartum for diagnosis has been challenged [2,3]. In a study by Elkayam et al [4], almost 20% of the patients developed symptoms of heart failure and were diagnosed with PPCM earlier than the last gestational month. A comparison between patients with early presentation and those with traditional criteria of PPCM revealed no significant differences in age, ethnic background, obstetrical history, and rate of gestational hypertension. Maternal outcome, left ventricular function at the time of diagnosis, and its recovery over time were also similar between the 2 groups. These findings indicate that PPCM and pregnancy-associated cardiomyopathy are part of the same clinical spectrum and some patients may present with PPCM symptoms earlier than the last gestational month. Hence, a position statement from a European Society of Cardiology working group on PPCM has eliminated the strict time limit to the diagnosis and expanded the definition of PPCM to “an idiopathic cardiomyopathy presenting with heart failure secondary to left ventricle systolic dysfunction towards the end of pregnancy or in the months following delivery, where no other cause of heart failure is
found” [5]. We think that PPCM is a diagnosis of exclusion and the time frame and echocardiographic cut-offs are arbitrary and can lead to underdiagnosis of PPCM. Birdal Yildirim MD Department of Emergency Medicine, Faculty of Medicine, Muğla Sıtkı Koçman University, Muğla, Turkey Corresponding author at: Faculty of Medicine, Muğla Sıtkı Koçman University, Orhaniye Mah. Haluk Özsoy Cad., 48000 Muğla, Turkey Tel.: +90 252 2115210 E-mail address: [email protected] Volkan Dogan MD Mustafa Ozcan Soylu MD Murat Biteker MD Department of Cardiology, Faculty of Medicine, Muğla Sıtkı Koçman University Muğla, Turkey http://dx.doi.org/10.1016/j.ajem.2015.04.045 References [1] McGregor AJ, Barron R, Rosene-Montella K. The pregnant heart: cardiac emergencies during pregnancy. Am J Emerg Med 2015;33(4):573–9. http://dx.doi.org/10.1016/j. ajem.2015.02.046 [pii: S0735–6757(15)00136–9]. [2] Biteker M, Kayatas K, Duman D, Turkmen M, Bozkurt B. Peripartum cardiomyopathy: current state of knowledge, new developments and future directions. Curr Cardiol Rev 2014;10(4):317–26. [3] Biteker M, Ilhan E, Biteker G, Duman D, Bozkurt B. Delayed recovery in peripartum cardiomyopathy: an indication for long-term follow-up and sustained therapy. Eur J Heart Fail 2012;14(8):895–901. [4] Elkayam U, Akhter MW, Singh H, Khan S, Bitan F, Hameed A, et al. Pregnancyassociated cardiomyopathy: clinical characteristics and a comparison between early and late presentation. Circulation 2005;11:2050–5. [5] Sliwa K, Hilfiker-Kleiner D, Petrie MC, Mebazaa A, Pieske B, Buncmann E, et al. Current state of knowledge on aetiology, diagnosis, management, and therapy of peripartum cardiomyopathy: a position statement from the Heart Failure Association of the European Society of Cardiology Working Group on peripartum cardiomyopathy. Eur J Heart Fail 2010;12(8):767–78.
0735-6757/© 2015 Elsevier Inc. All rights reserved.
Please cite this article as: Yildirim B, et al, Peripartum cardiomyopathy in the ED, Am J Emerg Med (2015), http://dx.doi.org/10.1016/ j.ajem.2015.04.045
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Correspondence
Peripartum cardiomyopathy in the ED To the Editor, We read with interest the review article recently published by McGregor et al [1] entitled “The pregnant heart: cardiac emergencies during pregnancy.” However, we have some concerns about the definition of peripartum cardiomyopathy (PPCM), which is a rare obstetric emergency. Presentation of PPCM in the emergency department is similar to that of patients presenting with heart failure due to other causes [2]. Diagnosis of PPCM is often missed or delayed because most of the signs and symptoms of normal pregnancy are similar to those of heart failure [2]. Peripartum cardiomyopathy should be differentiated from other forms of cardiomyopathy, heart failure, pulmonary thromboembolism, severe eclampsia, pneumonia, myocardial infarction, idiopathic dilated cardiomyopathy, and valvular heart disease. Peripartum cardiomyopathy has a number of definitions. McGregor et al defined PPCM as “left ventricle systolic dysfunction during the last month of pregnancy and the first 5 months after delivery.” However, the restriction of the time frame to last month of pregnancy or first 5 months postpartum for diagnosis has been challenged [2,3]. In a study by Elkayam et al [4], almost 20% of the patients developed symptoms of heart failure and were diagnosed with PPCM earlier than the last gestational month. A comparison between patients with early presentation and those with traditional criteria of PPCM revealed no significant differences in age, ethnic background, obstetrical history, and rate of gestational hypertension. Maternal outcome, left ventricular function at the time of diagnosis, and its recovery over time were also similar between the 2 groups. These findings indicate that PPCM and pregnancy-associated cardiomyopathy are part of the same clinical spectrum and some patients may present with PPCM symptoms earlier than the last gestational month. Hence, a position statement from a European Society of Cardiology working group on PPCM has eliminated the strict time limit to the diagnosis and expanded the definition of PPCM to “an idiopathic cardiomyopathy presenting with heart failure secondary to left ventricle systolic dysfunction towards the end of pregnancy or in the months following delivery, where no other cause of heart failure is
found” [5]. We think that PPCM is a diagnosis of exclusion and the time frame and echocardiographic cut-offs are arbitrary and can lead to underdiagnosis of PPCM. Birdal Yildirim MD Department of Emergency Medicine, Faculty of Medicine, Muğla Sıtkı Koçman University, Muğla, Turkey Corresponding author at: Faculty of Medicine, Muğla Sıtkı Koçman University, Orhaniye Mah. Haluk Özsoy Cad., 48000 Muğla, Turkey Tel.: +90 252 2115210 E-mail address: [email protected] Volkan Dogan MD Mustafa Ozcan Soylu MD Murat Biteker MD Department of Cardiology, Faculty of Medicine, Muğla Sıtkı Koçman University Muğla, Turkey http://dx.doi.org/10.1016/j.ajem.2015.04.045 References [1] McGregor AJ, Barron R, Rosene-Montella K. The pregnant heart: cardiac emergencies during pregnancy. Am J Emerg Med 2015;33(4):573–9. http://dx.doi.org/10.1016/j. ajem.2015.02.046 [pii: S0735–6757(15)00136–9]. [2] Biteker M, Kayatas K, Duman D, Turkmen M, Bozkurt B. Peripartum cardiomyopathy: current state of knowledge, new developments and future directions. Curr Cardiol Rev 2014;10(4):317–26. [3] Biteker M, Ilhan E, Biteker G, Duman D, Bozkurt B. Delayed recovery in peripartum cardiomyopathy: an indication for long-term follow-up and sustained therapy. Eur J Heart Fail 2012;14(8):895–901. [4] Elkayam U, Akhter MW, Singh H, Khan S, Bitan F, Hameed A, et al. Pregnancyassociated cardiomyopathy: clinical characteristics and a comparison between early and late presentation. Circulation 2005;11:2050–5. [5] Sliwa K, Hilfiker-Kleiner D, Petrie MC, Mebazaa A, Pieske B, Buncmann E, et al. Current state of knowledge on aetiology, diagnosis, management, and therapy of peripartum cardiomyopathy: a position statement from the Heart Failure Association of the European Society of Cardiology Working Group on peripartum cardiomyopathy. Eur J Heart Fail 2010;12(8):767–78.
0735-6757/© 2015 Elsevier Inc. All rights reserved.
Please cite this article as: Yildirim B, et al, Peripartum cardiomyopathy in the ED, Am J Emerg Med (2015), http://dx.doi.org/10.1016/ j.ajem.2015.04.045
