Clinical presentation, risk factors and six-month outcomes in Ugandan women with peripartum cardiomyopathy: prospective case-control study
Authors: Nabbaale J , Karen K S , Emmy E O , Annettee A N , Graham G C 
Published: October 2024

Abstract

Background
Peripartum Cardiomyopathy (PPCM) frequently affects women of African descent. There is scarcity of data pertaining to the clinical presentation and outcomes of PPCM patients in Uganda, particularly when employing modern diagnostic tools and adhering to guideline-directed medical therapy (GDMT).

Purpose
We aimed to delineate the clinical characteristics, echocardiographic findings, and 6-month outcomes among women in Uganda diagnosed with PPCM.

Methods
Prospective case-control design conducted from June 2022 to August 2023. We enrolled 80 PPCM cases and 80 matched controls. Inclusion criteria comprised: (i) peripartum state, (ii) signs and symptoms of HF, (iii) left ventricular (LV) ejection fraction ≤ 45%, and (iv) exclusion of alternative causes of HF. Controls were healthy women matched for age and parity. Over a 6-month period, enrolled PPCM cases were diligently monitored while on GDMT. All participants underwent a physical examination, 12-lead electrocardiography, and a detailed echocardiography incorporating global longitudinal strain measurements at both baseline and the 6-month follow-up.

Results
At baseline, amongst the cases, the mean age was 33.6 ± 6.6 years, mean parity was 3±2.1 pregnancies. HF onset occurred within 9.5±6.5 weeks post-delivery. A total of 20 (25.0%) cases presented in NYHA Class 4 with dyspnea as the predominant symptom in 79.95% of cases. Atrial fibrillation (AF) was observed in 2(2.5%) patients. In comparison with healthy controls, high gravidity (0.2±1.0; p&lt;0.001) was identified as the only predictor of PPCM in this study. (Table 1)
At 6-months follow up, the mean LV ejection fraction (LVEF) showed improvement from 35.7±-11.0% to 45.9 ± 15.7% (p&lt;0.001) accompanied by a reduction in left ventricular diameter (LVD) from 6.1±0.7 cm to 5.5±1cm(p&lt;0.001).
At the 6-month follow-up, recovery (LVEF ≥ 50%) occurred in 37 cases (55%), and 52 (65%)patients were asymptomatic (NYHA Class 1) at the 6-month follow-up. Six-month mortality data were available for 5(6.3%) women, and one patient successfully underwent the insertion of an Implantable Cardioverter-defibrillator for recurrent Ventricular Tachycardia.
Regarding GDMT, 55 participants received Bromocriptine as part of their medication. Twenty(25%) patients received anticoagulation for AF(n=2) or intracardiac thrombus (n=6, 1.67%) (Figure 1) resulting in 2(2.5%) strokes within the 6-month follow-up.

Conclusion
The current study demonstrated a comparable mortality rate on GDMT, aligning with contemporary global studies at 7.5%. The observed high thrombus burden in patients may indicate suboptimal adherence to anticoagulation therapy. While the incidence of PPCM remains undefined in Uganda, the primary predisposing factor identified was high gravidity. A noteworthy proportion of patients exhibited incomplete LV recovery, suggesting the need for larger studies to comprehensively define the maternal and fetal outcomes in Uganda.Figure 1Table 1