Rapid Review·Cardiovascular
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Cardiomyopathy
T1Must knowPeripartum Cardiomyopathy
Focus on
New HFrEF (EF < 45%) between the last month of pregnancy and 5 months postpartum with no other cause. Echo confirms it; treatment is HFrEF therapy modified for pregnancy (hydralazine-nitrate instead of ACE inhibitors before delivery), anticoagulation for very low EF, and a frank conversation about future pregnancy.
Key takeaways
What it is and who gets it
Idiopathic heart failure with reduced ejection fraction
it begins between 36 weeks of gestation and 5 months postpartum.A diagnosis of exclusion
every other cause of dilated cardiomyopathy is ruled out, in a woman with no heart disease before the final month of pregnancy.African American women
account for over 40 percent of cases in the United States.Other risk factors
maternal age over 30, multiple gestation, pre-eclampsia or eclampsia.Timing
most common in the first month after delivery, but it can appear in the third trimester.Clinical features and diagnosis
Heart failure that hides in pregnancy
the signs and symptoms overlap with the normal changes of late pregnancy and the postpartum period.Next step
progressive exertional dyspnea, leg edema, a holosystolic murmur and an S3 in late pregnancy call for an echocardiogram.Echocardiography
left ventricular ejection fraction under 45 percent.- It may also show ventricular dilation, functional mitral and tricuspid regurgitation, and pulmonary hypertension.
Other tests
chest radiograph shows cardiomegaly; B-type natriuretic peptide (BNP) and troponin I are raised.Management
Standard systolic heart failure treatment
modified for pregnancy and lactation safety (Heart Failure).Acute decompensation
stabilize; oxygen and diuretics for symptoms.Anticoagulation
for a confirmed thromboembolic event or an ejection fraction of 30 to 35 percent or less, because of the thromboembolic risk.Urgent delivery
for a hemodynamically unstable patient who does not respond to medical therapy.Prognosis and future pregnancy
Recovery
many women recover partially or completely within 6 months of delivery; some need lifelong heart failure care.Recurrence risk
persistent left ventricular dysfunction (ejection fraction under 50 percent) means a high risk of deterioration in a future pregnancy.- Highest when the ejection fraction was under 20 percent at diagnosis.
Counseling
advise delaying pregnancy until ventricular function has been normal for at least 6 months.- Manage any later pregnancy with an obstetric-cardiology team.
- Serial echocardiograms continue for several years regardless of recovery; recurrent or persistent dysfunction means advising against pregnancy.
Two weeks after delivery, a 34-year-old with twins and pre-eclampsia has dyspnea, edema and an S3. What is the next step, and what ejection fraction supports the diagnosis?
Suspect peripartum cardiomyopathy (age over 30, multiple gestation and pre-eclampsia are risk factors; the first month after delivery is the most common time). The next step is an echocardiogram; a left ventricular ejection fraction under 45 percent, with other causes excluded, supports it.
How it's tested
Three weeks postpartum with orthopnea, crackles, an S3 and EF 28% with no other cause: peripartum cardiomyopathy — treat as acute HFrEF; ACE inhibitor is now allowed postpartum (compatible with breastfeeding).
36 weeks pregnant with new systolic failure who needs afterload reduction: hydralazine plus nitrates — ACE inhibitors and ARBs wait until delivery.
Pregnant patient in cardiogenic shock unresponsive to medical therapy: stabilize the mother and deliver urgently.
EF 22% at diagnosis, now 40% at six months; she asks about another pregnancy: advise against it — persistent dysfunction carries a high risk of deterioration; revisit only if EF normalizes for ≥ 6 months.
Peripartum cardiomyopathy with EF 25% and no thrombus: anticoagulate — peripartum hypercoagulability plus a low EF.
Go deeper
Guidelines: 2025 ESC Cardiovascular Disease in Pregnancy Guideline · 2022 AHA/ACC/HFSA Heart Failure Guideline
Related Step 2 pages: Dilated Cardiomyopathy, Heart Failure
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