June 2018 at a Glance: Peripartum Cardiomyopathy and Pathophysiology, Prognosis, and Device Therapy of Heart Failure

Outcome of patients with peripartum cardiomyopathy (PPCM) varies from full recovery to residual left ventricular systolic dysfunction, persistent heart failure (HF) and death. In a recent analysis of 411 patients in a prospective registry by the EURObservational Research Programme and the Heart Failure Association (HFA), patients with PPCM had a 2.4% mortality, an 80–90% rate of persistent HF symptoms and a 6.8% rate of thromboembolic events in the first month.1 PPCM has also a major impact on subsequent pregnancies with a high rate of left ventricular dysfunction relapse or death at 6 months (56% and 12%, respectively).2 The HFA practical guidance paper in this issue of the Journal is therefore particularly welcome. It summarizes current evidence for long-term outcome, risk stratification of further pregnancies and overall management of patients with PPCM.3 Lindgren et al.4 studied the relationship between cognitive performance and subsequent risk of HF using a cohort of 1 225 300 Swedish men (mean age 18.3 years), enrolled in mandatory military conscription in 1968–2005. The incidence of HF was estimated as HF hospitalization until 2014 using data from the Swedish National Inpatient Registry. There were 7633 new cases of HF hospitalization. A strong inverse relationship between global cognitive performance and risk of HF hospitalization, persistent after adjustment for baseline variables and co-morbidities, was found.4 MicroRNAs continue to be a major target of research in HF.5 De Rosa et al.6 measured plasma microRNAs in samples from the aorta and the coronary venous sinus in patients with HF and control subjects. A positive transcoronary gradient, consistent with cardiac release, was found for different microRNAs in patients with HF of ischaemic and non-ischaemic aetiology. Zymlinski et al.7 evaluated the prevalence and clinical significance of elevated blood lactate levels in patients hospitalized for acute HF without overt clinical evidence of peripheral hypoperfusion. Among the 237 studied patients, 103 (43%) had elevated blood lactate (≥2 mmol/L). These patients had higher levels of markers of myocardial, hepatic and renal dysfunction or damage, and higher 1-year mortality (36% vs. 21%; P < 0.05). After adjustment for other well-established prognostic variables, blood lactate on admission remained predictive of a poorer outcome. A lower proportion (25%) of patients with increased blood lactate levels was recently reported by Adamo et al.8 who, however, studied clinically stable patients with advanced HF. The role of heart rate (HR) as a prognostic variable in cardiovascular disease and, namely, HF is well established.9 Bohm et al.10 assessed the prognostic impact of resting HR and systolic blood pressure (SBP) in 1377 patients enrolled in the International Takotsubo Registry. Both high HR and low SBP were associated with higher mortality and major adverse cardiac and cerebrovascular event rates. This relationship remained significant at multivariable analysis so that, at HR >70 b.p.m., every 1 b.p.m. increase was associated with a 1.7% increase in mortality and at SBP <130 mmHg, every 1 mmHg increase was associated with a 2% risk reduction.10 Thus, both high HR and low SBP predict poorer outcomes in Takotsubo syndrome. Diabetes is one of the most important co-morbidities of HF. Increasing co-morbidity burden has been associated with higher mortality and lower likelihood of implantable cardioverter-defibrillator (ICD) interventions before death in a recent cohort study in Denmark.11 Consistent data come from a patient-level combined analysis of 3359 patients from four primary prevention ICD trials. The effects of ICD implantation in patients with HF and concomitant diabetes (n = 996) were compared with those without diabetes (n = 2363).12 ICDs were associated with a reduced risk of all-cause mortality among patients without diabetes [hazard ratio (HR) 0.56, 95% confidence interval (CI) 0.46–0.67] but not among those with diabetes (HR 0.88, 95% CI 0.7–1.12; interaction P = 0.015).12 Thus, the magnitude of benefit of ICD implantation was significantly reduced in patients with diabetes. These findings were likely caused by the increased burden of non-arrhythmic death in these patients and, according to the Authors, may warrant further studies of ICD efficacy in patients with HF and diabetes.12 Dickstein et al.13 show the results of CRT Survey II conducted by the HFA and the European Heart Rhythm Association. This second survey followed the first one in 2008–2009 and was conducted from October 2015 to December 2016 in 42 European Society of Cardiology member countries. It enrolled 11 088 patients representing 11% of the total number of expected implantations in participating countries during the survey period. Among all the CRT implantations, 28% were upgrades from a permanent pacemaker or ICD and 30% were CRT-P rather than CRT-D. Most patients (88%) had a QRS duration ≥130 ms, 73% had left bundle branch block and 26% were in atrial fibrillation at the time of implantation. A full picture of current clinical practice of CRT in European countries, with large geographical variations, is given.13 Treatment of right ventricular failure and of tricuspid regurgitation (TR) remains a major unmet need.14, 15 Orban et al.16 report the 6-month results of transcatheter edge-to-edge tricuspid valve repair in 50 patients with right-sided HF and severe TR. Fourteen patients were treated for isolated TR and 36 patients for combined mitral and tricuspid regurgitation. At 6-month follow-up, a persistent reduction of at least one echocardiographic TR grade was achieved in 90% of patients and New York Heart Association class improved in 79% of patients. The 6-minute walk distance increased by 44%, the median N-terminal pro-B-type natriuretic peptide decreased by 30%, and the quality of life score improved by 16%. The improvements were comparable in patients undergoing isolated TR or combined mitral and tricuspid regurgitation treatment. During follow-up, 8 patients died, 14 were hospitalized for worsening HF, 2 underwent tricuspid valve surgery, and 2 received a second percutaneous procedure.16

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