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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 28, No 1, January/February 2017
8
AFRICA
Peripartum cardiomyopathy among cardiovascular
patients referred for echocardiography at Parirenyatwa
Teaching Hospital, Harare, Zimbabwe
Ellise Tapiwa Gambahaya, James Hakim, David Kao, Noleen Munyandu, Jonathan Matenga
Abstract
Objectives:
The main aim was to evaluate the outcome of
patients with peripartum cardiomyopathy (PPCM) within
six months of diagnosis. The secondary aim was to describe
demographic and clinical characteristics of patients with
PPCM in Harare, Zimbabwe.
Methods:
This was a prospective cohort study in which
patients recruited into a detailed PPCM registry were followed
up for six months. Echocardiograms were performed at enrol-
ment, and three and six months after diagnosis, to determine
left ventricular function.
Results:
From 1 August 2012 to 31 July 2013, 43 patients with
a new diagnosis of PPCM were recruited at Parirenyatwa
Hospital in Harare. At six months, mean ejection fraction
improved from 29.7
±
9.8 to 44.9
±
14.9%,
p
<
0.001 and New
York Heart Association (NYHA) functional class improved
significantly (
p
<
0.0001). Five (11.6%) patients died.
Conclusions:
Left ventricular function improved in a substan-
tial number of patients (42.9%) in this Zimbabwean cohort
compared to other African cohorts. However the mortality
rate remained high.
Keywords:
peripartum cardiomyopathy, Zimbabwe, outcomes
Submitted 17/3/15, accepted 3/4/16
Cardiovasc J Afr
2017;
28
: 8–13
www.cvja.co.zaDOI: 10.5830/CVJA-2016-043
Cardiovascular disease has reached epidemic proportions in
sub-Saharan Africa and is a major contributor to morbidity
and mortality.
1
These conditions often affect young women
disproportionately, particularly during pregnancy, and they
may have a worse prognosis compared to other groups of
patients.
2
Peripartum cardiomyopathy (PPCM) is one such
condition that affects previously healthy young women during
the most productive years of their lives. This has far-reaching
consequences for the patient, children and family unit as a whole.
Virchow recognised heart failure in associationwith pregnancy
as early as the 18th century.
3
However, it was not until the 1930s
when Hull and Hafkesbring formally described the syndrome of
heart failure following pregnancy, which they called ‘postpartum
cardiomyopathy’.
4
Demakis and Rahmitoola in 1971 formally
defined PPCM and gave criteria for its diagnosis, the basis of
which remains today.
5
Since the original description by Demakis, several studies
have assessed the clinical profile of patients with PPCM as well
as the natural history of the condition. These studies have been
done in a variety of settings with the majority emanating from
the United States and South Africa. Data from these studies
suggest that PPCM has a variable clinical course. Unlike many
other forms of cardiomyopathy, patients with PPCM are known
to recover fully from the condition. When it occurs, recovery is
rapid, usually within the first six months after diagnosis.
5
Series from the United States and South Africa show that
21 to 78% of patients with PPCM recover left ventricular
function (LVEF
≥
50%) within six months of diagnosis.
6-9
However a proportion of patients never recovers and requires
long-term management of chronic heart failure. These women
often have relapses of decompensated cardiac failure that may
be severe enough to require cardiac transplantation. Factors
shown to be associated with recovery of left ventricular function
include Caucasian race, higher New York Heart Association
(NYHA) functional class, higher ejection fraction and smaller
left ventricular dimensions at presentation.
6,10
Typical causes
of death in PPCM patients include progressive cardiac failure
and sudden cardiac death, presumably due to arrhythmias and
thromboembolic events.
11
PPCM is known to occur more commonly in African
women or those of African descent, but despite the potentially
devastating consequences of PPCM, there is very little published
data about its outcome in African women outside South Africa,
and a few isolated historical reports from Nigeria.
12
A study
conducted in Haiti showed an incidence of PPCM of one in 350
live births, which is at least 10 times that of Western nations.
13
In South Africa the estimated incidence is one in approximately
1 000 live births.
14
Given these data, it is expected that Zimbabwe would be a
setting with a relatively high prevalence of PPCM, the impact
of which may be magnified by poorly resourced public hospitals
that make the diagnosis and management of these patients
suboptimal. Therefore, it was necessary to conduct the current
study to look at the outcome of PPCM in Zimbabwe. Clinical
characteristics of Zimbabwean PPCM patients were described,
and change in left ventricular function, functional status, and
overall survival within six months of diagnosis were evaluated.
College of Health Sciences, University of Zimbabwe,
Harare, Zimbabwe
Ellise Tapiwa Gambahaya, MB ChB, MMed,
egambahaya@gmail.comJames Hakim, MB ChB, MMed, MMedSc, FRCP
Noleen Munyandu, MB ChB, MMed
Jonathan Matenga, MB ChB, MSc, FRCP
Division of Cardiology, Department of Medicine, University
of Colorado Denver School of Medicine, Colorado, USA
David Kao MD