James D Fett MD Educational Links
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Graph/Link Updated 2020 PPCM puzzle
Updated 2019 report on PPCM puzzle:
Epidemiology and outcomes of peripartum cardiomyopathy in the United States: findings from the Nationwide Inpatient Sample:
Global Left Ventricular Strain at Presentation Is Associated with Subsequent Recovery in Patients with Peripartum Cardiomyopathy:
African-American Women Have a Higher Risk for Developing PPCM -
Dr. James Fett / Pathogenesis PPCM
IPAC Research & Medical Centers:
A leading research study group in North America, IPAC Labs (Investigations of Pregnancy Associated Cardiomyopathy) is funded by the United States National Heart, Lung, and Blood Institute of the National Institution of Health (NIH); IPAC have recently documented improved possible recovery levels of PPCM to greater than 90 % of victims when diagnosis can be made in the early stages. IPAC Labs have been working tirelessly and is now expanding their study to an amazing 50 medical centers in the USA and Canada, up from the current 30 and is directed by Dr. Dennis M. McNamara, Cardiologist, at the University of Pittsburgh Medical Center. Again, we believe that no mother should die from PPCM and that every PPCM mother should be able to fully recover and experience their child. The goal is within our reach; we need your help.
We want to know what causes Peripartum Cardiomyopathy on a molecular level. IPAC case studies provide us with a leading-edge look into the underlying causes of PPCM and how to further prevent the disease. While the direct underlying cause is still unknown, there are ways to prevent full blown cardiac arrest and mortality if caught in time. We are learning more and more everyday; with your generosity, we can help further the knowledge of trusted health care professionals to hopefully one day put to rest Peripartum Cardiomyopathy, not another mother, daughter, wife, partner.
Heart failure in young women related to pregnancy is called Peripartum Cardiomyopathy (PPCM) or pregnancy-associated-cardiomyopathy (PAC). PPCM occurs all over the world and is one of the leading causes of maternal mortality and is reported in roughly 1 in 2000 pregnancies. PPCM holds no discrimination toward age, race or heritage, etc. however, incidences seem to be twice as common in African & Black-Americans compared to other races and nationalities... Even women in PERFECT health can develop PPCM. Peripartum Cardiomyopathy is a pregnancy induced heart failure that can be cured durning pregnancy. If untreated the condition worsens and peaks right after delivery. Most PPCM pregnancies are untreated. This is why the death rate is almost as high as Cancer solely due to lack of awareness to the public, the medical wheelhouse and within the medical communities globally. There is a practical solution to this serious life threatening problem. The cure, "Raise The Standard Screening, Testing and Labs" with Implementing, The Pro B-Type natriuretic peptide (NT-pro BNP- BPN ) & (EKG) Echocardiograms as mandatory treatments of care durning and after to all pregnancies. Early diagnosis saves lives! The objective treatment is to keep extra fluid from accumulating in the lungs & to help the heart recover as fully as possible. PPCM is usually misdiagnosed as Preeclampsia & Gestational Diabetes. PPCM is more common than we think. There are approximately 2000 new cases each year in the USA. Thanks to increasing understanding of the causes and treatment of PPCM, mortality rates have decreased from over 30 % to current rates under 1%… Despite that, PPCM remains one the top silent killers of new mothers in the USA.This is unacceptable! One of the leading causes of PPCM appears to be an imbalance of proteins coming from the placenta, producing a cardio-toxic “angiogenic imbalance”, leading to heart failure and death. It is possible to predict who is at higher risk of developing PPCM by measuring these proteins in the blood. PPCM prevention depends upon funding so that promising new treatments can be identified and verified as effective, leading to full recovery and making relapse in subsequent pregnancies much less likely-even preventable in the first place. IPAC researchers believe that no mother should die from PPCM & mothers should fully recover if treated. This goal is within our reach; but we need everyones’ support to manage this healthy pregnancy movement and save families & lives. Woman have been giving birth since the beginning of time, enough girls have suffered and died. We should not be just in the early stages of this awareness. We fight the fight to be heard for others that no longer have a voice.
A leading research study group in North America, IPAC (Investigations of Pregnancy-Associated Cardiomyopathy), funded by the United States National Heart, Lung, and Blood Institute of the National Institution of Health (NIH), has documented improving full recovery levels of PPCM to greater than 90 % of victims when diagnosis can be made in the stage with less severe heart failure. IPAC’s work continues and is expanding its study from 30 to 50 medical centers in the USA and Canada, directed by Dr. Dennis M. McNamara, Cardiologist, at the University of Pittsburgh Medical Center. Again, we believe that no mother should die from PPCM and that all PPCM mothers should fully recover. This goal is within our reach; but we need your help."
IPAC investigations have demonstrated that there are no adverse effects of breastfeeding on recovery from PPCM. However, some who treat PPCM feel that it is absolutely mandatory to stop breastfeeding if one has PPCM; and to use bromocriptine-inhibition of prolactin, particularly in those who have more severe systolic dysfunction at diagnosis. At the same time, others who treat PPCM realize that the use of bromocriptine in a peripartum setting is potentially dangerous; (7-9) and also realize that truly controlled, randomized studies of PPCM subjects with both “use” and “non-use” of bromocriptine are still needed. (10) Whenever bromocriptine is used it is important to also use anti-coagulation treatment in order to help avoid the thrombotic/embolitic complications of its use. Adequately controlled studies should be done to clarify the role of prolactin metabolites in the development of PPCM. One of the IPAC goals is to carry out such a study. But that type of investigation would not even be a priority issue if PPCM could be diagnosed at an earlier stage. (11) We would never have to face the issue of “use” compared to “non-use” of the prolactin hormone inhibition by treatment with bromocriptine if we could diagnose PPCM with an initial LVEF above 35 %. In that situation, almost all, if not all, subjects would recover using standard recommended heart failure treatment.
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Stated by Dr. James Fett November 14, 2019
“Many factors could contribute to that observation. I will say that the highest incidence of PPCM I have encountered is from Haiti, 1 case per 400 births--and in Haiti none of those PPCM mothers received IVF or other fertility treatments. For those countries where IVF occurs, important to observe closely for subsequent complications, including PPCM."
Fertility treatment linked to peripartum cardiomyopathy:
This is an example of what can happen with late diagnosis: (4 months postpartum) of PPCM.
We continue to advocate for more awareness of the possibility for PPCM to develop and making an earlier diagnosis, even a prenatal diagnosis:
J Pak Med Assoc. 2019 Aug;69(8):1216-1218.
A case of peripartum cardiomyopathy presenting as bilateral acute limb ischaemia and gangrene.
Ashraf A1, Zahid S2, Ahmad Z2, Zia Ur Rehman A3, Faheem M1.
Department of Cardiology, Medical Teaching Institution, Khyber Teaching Hospital.2Medical Teaching Institution, Khyber Teaching Hospital.3Final Year Medical Student,
Khyber Medical College, Peshawar, Pakistan.
Peripartum cardiomyopathy (PPCM) is a condition of unknown etiology that presents as heart failure due to left ventricular systolic dysfunction in the last of month of pregnancy and up to six months after giving birth. PPCM predisposes towards thrombo-embolism and an acute limb ischaemia can be a manifestation of this disease. We present a case of a 23-year-old lady presenting an acute lower limb ischaemia four months post-partum. Doppler ultrasound showed bilateral femoral emboli and cardiac ECHO showed a 24% ejection fraction. Amputation was performed on both limbs, below her right knee and above her left knee. The patient was started on heart failure medication and her symptoms improved with diuretic therapy, confirming the diagnoses of PPCM. It is important to recognize acute limb ischaemia as a rare manifestation of PPCM, as a timely diagnosis and effective treatment of the disease can improve the prognosis. We believe this is the first case to be reported in medical literature from Pakistan of a patient presenting PPCM with bilateral acute limb ischaemia and gangrene.
Learn More about "The Silent Killer" CDC Reports
Morbidity & Mortality in Chronic Heart Failure
Daily dosage 100 to 300 mg/day. The Effect of Coenzyme Q10 on Morbidity and Mortality in Chronic Heart Failure
JACC: Heart Failure
This controlled, multicenter trial randomized 420 patients with moderate to severe heart failure to receive coenzyme Q10 or placebo. At the 2-year endpoint, cardiovascular mortality, all-cause mortality, and hospitalization for heart failure were significantly lower in those receiving coenzyme Q10.
Coenzyme Q10 supplements should be considered in the management of heart failure given the potentially significant mortality benefit and reduction in major adverse cardiac events.
– Samer Ajam, MD
Written by Douglas L Mann MD
The long-awaited results of the effect of coenzyme Q10 on morbidity and mortality in chronic heart failure (Q-SYMBIO) trial have just been published. The rationale for this study, which was conducted by Dr. Svend Mortensen and colleagues, is that coenzyme Q10 (CoQ10), which occurs naturally in the body and is essential for cardiac energetics and survival, is known to be decreased in the myocardium of patients with heart failure in relation to heart failure severity.
The Q-SYMBIO trial randomized 420 patients with severe heart failure (NYHA class III or IV) to CoQ10 (100 mg three times daily) or placebo and followed them for 2 years. The primary endpoint for this trial, which took over 10 years to complete and was stopped prematurely because of low recruitment, was a composite of major adverse cardiovascular events (MACE), defined as an unplanned hospital stay from worsening heart failure, cardiovascular death, mechanical assist device, or urgent cardiovascular transplantation, using a time-to-first-event analysis. Mortensen and colleagues showed that, when compared with placebo, CoQ10 halved the risk (P = .003) for a MACE, and halved the risk for all-cause death (P = .018). The authors also showed that treatment with CoQ10 significantly reduced cardiovascular mortality and the incidence of hospital stays for heart failure.
Although Q-SYMBIO met its primary prespecified MACE endpoint, the striking results of this trial should not be viewed as definitive until they can be replicated in a larger clinical trial. Statistical methodologists have emphasized repeatedly that a small number of deaths in small clinical trials results in a very imprecise estimate of risk reduction, which is not frequently replicated in subsequent trials. Further, the probability that a research finding is true depends on the plausibility of the hypothesis that is being tested (ie, pretest likelihood).
The biological plausibility that supplementation with CoQ10, which may act as an antioxidant, can lead to a 50% reduction in mortality, when prior trials with antioxidant vitamins have shown that antioxidants are at best not beneficial and at worst harmful,1 begs credulity. Because of the heterogeneity in heart failure populations, we have learned through experience that, when something appears to be too good to be true in small clinical trials, it is almost always the result of chance.
The results of the Q-SYMBIO study are provocative, and Mortensen and colleagues are to be congratulated on completing a difficult clinical trial with very little support for the trial. However, until the results of the Q-SYMBIO study can be replicated in a larger clinical trial that has more clinical events, it is probably premature to tell your patients with heart failure to start taking CoQ10.
Myung SK, Ju W, Cho B, et al. Efficacy of vitamin and antioxidant supplements in prevention of cardiovascular disease: systematic review and meta-analysis of randomized controlled trials. BMJ. 2013;346:f10.
PPCM Awareness Day Is Everyday!