CARDIOVASCULAR JOURNAL OF AFRICA • Vol 23, No 6, July 2012
322
AFRICA
The 12-lead ECG in peripartum cardiomyopathy
KEMI TIBAZARWA, GERALDINE LEE, BONGANI MAYOSI, MELINDA CARRINGTON, SIMON STEWART,
KAREN SLIWA
Abstract
Background:
The value of the 12-lead electrocardiogram
(ECG) to provide prognostic information in the deadly and
disabling syndrome peripartum cardiomyopathy (PPCM) is
unknown.
Aims:
To determine the prevalence of major and minor ECG
abnormalities in PPCM patients at the time of diagnosis, and
to establish whether there are ECG correlates of persistent
left ventricular dysfunction and/or clinical stability at six
months of follow up, where available.
Methods:
Twelve-lead ECGs were performed at the point of
diagnosis on 78 consecutive women presenting with PPCM
to two tertiary centres in South Africa and 44 cases (56%) at
the six-month follow up. Blinded Minnesota coding identified
major ECG abnormalities and minor ECG changes.
Results:
The cohort mainly comprised young women of black
African ancestry (90%) [mean age 29
±
7 years and median
body mass index 24.3 (IQR: 22.7–27.5) kg/m
2
]. The major-
ity of cases (
n
=
70; 90%) presented in sinus rhythm (mean
heart rate 100
±
21 beats/min). At baseline, at least one ECG
abnormality/variant was detected in 96% of cases. Major
ECG abnormalities and minor changes were detected in 49%
(95% CI: 37–60%) and 62% (95% CI: 51–74%) of cases,
respectively; the most common being T-wave changes (59%),
p-wave abnormality (29%) and QRS-axis deviation (25%).
Of the 44 cases (56%) reviewed at six months, normalisa-
tion of the 12-lead ECG occurred in 25%; the most labile
ECG features being heart rate (mean reduction of 27 beats/
min;
p
<
0.001) and abnormal QRS axis (36 vs 14%;
p
=
0.014). On an adjusted basis, major T-wave abnormalities
on the baseline 12-lead ECG were associated with lower
left ventricular ejection fraction (LVEF) at baseline (aver-
age of –9%, 95% CI: –1 to –16;
p
=
0.03) and at six months
(–12%; 95% CI: –4 to –24;
p
=
0.006). Similarly, baseline
ST-segment elevation was also associated with lower LVEF
at six months (–25%; 95% CI: –0.7 to –50;
p
=
0.04).
Conclusions:
In this unique study, we found that almost all
women suffering from PPCM had an ‘abnormal’ 12-lead
ECG. Pending more definitive studies, the ECG appears to
be a useful adjunctive tool in both screening and prognostica-
tion in resource-poor settings.
Keywords:
peripartum cardiomyopathy, ECG, baseline, follow
up, comparative study, South Africa
Submitted 5/5/11, accepted 17/1/12
Published online 15/2/12
Cardiovasc J Afr
2012;
23
: 322–329
DOI: 10.5830/CVJA-2012-006
Peripartum cardiomyopathy (PPCM) is a form of heart failure
(HF) with poorly understood aetiology, occurring between the
last trimester of pregnancy and up to the first five to six months
postpartum.
1,2
Despite an early definition,
3
later modified by
Pearson and colleagues,
4
there is no consensus regarding PPCM
as a single entity among the leading cardiology societies.
5
The
European Society of Cardiology recently declared PPCM a
distinct disease entity,
1
although it may take time before wider
awareness of PPCM facilitates more timely diagnosis and
pro-active treatment. This is unfortunate given that PPCM causes
left ventricular (LV) dysfunction, is more common in particular
populations (e.g. African women
6
) and is associated with poor
clinical outcomes and survival rates.
7,8
Some studies suggest the incidence of PPCM is one in
3 000 live births. However, one African study found it to be one
in 1 000 live births.
9
There is also a very high risk of relapse in
subsequent pregnancies,
10,11
even following full recovery of LV
function after the first pregnancy.
6
Therefore, early and definitive
diagnosis of PPCM is essential to limit the high risk of morbidity
and mortality in both current and subsequent pregnancies.
Definitive diagnosis and subsequent management of PPCM
requires a high index of suspicion. It also usually requires referral
to a tertiary centre for echocardiographic studies and specialist
cardiological management. Anecdotal evidence suggests that
many women who initially present with signs and symptoms
indicative of PPCM are diagnosed with ‘non-specific symptoms
of the puerperal period’. The misdiagnosis of PPCM (often
leading to clinical deterioration and in some instances death)
represents a clear target for early intervention and prevention.
Until specific aetiologies are identified, PPCM remains a
diagnosis of exclusion.
Women in their peripartum period suspected with PPCM
require rigorous investigation; a costly and laborious process for
the patient and healthcare provider. This is particularly difficult in
a resource-poor environment. Although screening with (point-of-
care derived) brain natriuretic peptide (BNP) levels may offer a
means of detecting elevated atrial pressures secondary to systolic
dysfunction (particularly given the age of those affected
6,12,13
),
Hatter Institute for Cardiovascular Research in Africa,
Department of Medicine, Faculty of Health Sciences,
University of Cape Town, South Africa
KEMI TIBAZARWA, MD, MPH
BONGANI MAYOSI, D Phil, FCP (SA)
KAREN SLIWA, MD, PhD,
Soweto Cardiovascular Research Unit, Chris Hani
Baragwanath Hospital, University of the Witwatersrand,
Johannesburg, South Africa
KEMI TIBAZARWA, MD, MPH
MELINDA CARRINGTON, PhD
SIMON STEWART, PhD
KAREN SLIWA, MD, PhD
Baker IDI Heart and Diabetes Institute, Melbourne, Australia
GERALDINE LEE, MPhil
MELINDA CARRINGTON, PhD
SIMON STEWART, PhD
