Cardiovascular Journal of Africa: Vol 28 No 1 (January/February 2016)

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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 28, No 1, January/February 2017 12 AFRICA
(42.1–44.1%) and Zimbabwean patients (44.9%) despite the fact
that fewer patients in Zimbabwe had access to beta-blockers.
Similarly, the proportion of patients who fully recovered left
ventricular function in Zimbabwe was similar to Western cohorts.
Although beta-blockers have been shown to improve outcomes
in patients with systolic dysfunction, their efficacy in patients of
African ancestry has been questioned.27 A GRK5 polymorphism
seen in black patients actually gives genetic beta-blockade and
improves survival in African patients.28 A meta-analysis also
confirmed no significant overall benefit of beta-blockade in black
patients with NYHA class III/IV heart failure.29
Four of the patients (9%) had intramural thrombi on
enrollment, and three out of the five patients who died had
thrombotic complications. This is consistent with previous
observations that PPCMis aprothrombotic state.30,31 This supports
the recommendation by some experts that anticoagulation
should be prescribed to women with PPCM with very low
ejection fractions. This is in contrast to recommendations for
use of anticoagulation in patients with systolic dysfunction from
other causes who are in sinus rhythm.32
Limitations
This study has several limitations. Firstly, the study had a short
follow-up period of only six months. In previous studies, the
improvement in left ventricular function continued even after the
initial six months. Sliwa et al. also showed that the mortality rate
actually increased after the first six months, and a proportion
of patients who recovered within the first six months still died
within two years of diagnosis.11 Hence it would have been
interesting to observe the long-term outcome in this group of
patients.
Secondly, the sample of patients in this study may not
have been representative of the patients who develop PPCM
in Zimbabwe. For example, only patients who presented for
echocardiography were included in this study. Hence women
who were not able to get an echocardiogram for various
reasons, such as financial constraints, were missed. However it
is important to note that Parirenyatwa Hospital was the only
public institution offering echocardiography for the whole
northern region of the country. The only other public institution
offering echocardiography is Mpilo Hospital which is some
400 km from Harare and caters for the southern region of the
country. Therefore the catchment area for the study was quite
wide although the majority of patients came from in and around
Harare.
Lastly, patients presented at different stages in their illness
after having received some form of treatment. This was largely
due to the fact that most patients presented for investigation only
when they had money for the echocardiogram.
Conclusion
In this study, Zimbabwean PPCM patients were younger and
of lower parity than those in previously published studies
from Africa, with a relatively high proportion of patients
with pregnancy-induced hypertension. The percentage of
Zimbabwean patients who recovered left ventricular function by
six months was almost double that seen in other PPCM patients
with similar ethnicity, although the mortality rate was similar
to that observed in other African cohorts. These outcomes
occurred despite limited access to medications such as beta-
blockers, which have been shown to improve outcomes in heart
failure. A large percentage of patients who died had a high rate
of thrombotic complications, supporting the recommendation
that patients with PPCM should receive anticoagulation when
in the setting of a low ejection fraction. Further research to
assess the differences in pathogenesis, treatment and outcomes
in Zimbabwean PPCM patients is warranted.
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