Global prevalence of mortality and LV recovery in women with PPCM – a systematic review and meta-analysis
Authors: Hoevelmann J , Engel M E , Muller E , Hohlfeld A , Boehm M , Sliwa K , Viljoen C A 
Published: October 2022

Abstract

Introduction
Peripartum cardiomyopathy (PPCM) remains a major contributor to maternal morbidity and mortality worldwide. The disease is associated with various complications mainly occurring early during its course. Reported adverse outcomes include decompensated heart failure, thromboembolic complications, arrhythmias and death.

Purpose
We aimed to systematically summarize the outcomes of women with PPCM across different geographical regions and to identify possible predictors of adverse outcomes.

Methods
For this systematic review and meta-analysis, we performed a comprehensive search of all articles published between January 2000 and June 2021 on PubMed/MEDLINE, Web of Science, Scopus and EBSCO Host, including Academic Search Premier, Africa-Wide Information, CINAHL. All cohort, case-control and cross-sectional studies, as well as control arms of randomized controlled trials (RCTs) reporting on the in-hospital complications and 6- and/or 12-month outcomes of PPCM were considered eligible.

Results
Forty-seven studies (4875 participants across 60 countries) met the eligibility criteria. Hemodynamic and echocardiographic parameters were similar across all continents. In-hospital mortality was reported as 1.9% [95% CI 0.5–4.0] across all regions. About 10% of patients received invasive ventilation, 21.5% inotropic and 3.1% received mechanical support, respectively. Left ventricular (LV) thrombus complicated 9.0% [95% CI 6.5–11.9] of patients and all-cause embolic events (i.e., stroke, arterial embolism, deep vein thrombosis, pulmonary embolus) occurred in 6.1% [95% CI 3.8–8.9]. Arrhythmias were seldomly reported. All-cause mortality was 8.0% [95% CI 5.5–10.8, I2=79,1%) at 6 months and 9.8% [95% CI 6.2–14.0], I2=80.48%) at 12 months respectively. Overall, 44.4% ([95% CI 36.2–52.8], I2=91.7%) of patients recovered their LV function within 6 months and 58.7% ([95% CI 48.1–68.9], I2=75.8%) within 12 months, respectively. The lowest rate of LV recovery was reported by studies conducted in the Middle East (13.6% [95% CI 9.5–18.1], 3 studies), whereas the highest rate of LV recovery was reported for patients from Europe (56.8% [95% CI 38.1–74.7], 6 studies, I2=93.3%). All-cause mortality was highest in Africa and Asia/Pacific. Europe and North America reported the highest prevalence of LV recovery. (Figure 1) Frequent prescription of beta-blockers, ACE-I/ARB and bromocriptine/cabergoline treatment was associated with significantly lower all-cause mortality and better LV recovery (Figure 2).

Conclusion
We identified significant global differences in prescribed treatment, prevalence of in-hospital complications and six- and 12-month outcomes. Frequent prescription of guideline-directed heart failure therapy was associated with better LV recovery and lower all-cause mortality. Timely initiation and up-titration of heart failure therapy should therefore be strongly encouraged to improve outcome in women with PPCM.

Funding Acknowledgement
Type of funding sources: None.