Review Article on Cardiovascular Diseases in Low- and Middle-Income Countries
Detection and management of arrhythmias in peripartum
cardiomyopathy
Julian Hoevelmann1,2#, Lina Hähnle1#, Julia Hähnle1, Karen Sliwa1,3, Charle Viljoen1,3
1
Hatter Institute for Cardiovascular Research in Africa, University of Cape Town, Cape Town, South Africa; 2Department of Cardiology and
Angiology, Hannover Medical School, Hannover, Germany; 3Division of Cardiology, University of Cape Town, Cape Town, South Africa
Contributions: (I) Conception and design: All authors; (II) Administrative support: None; (III) Provision of study materials or patients: None; (IV)
Collection and assembly of data: J Hoevelmann, L Hähnle, J Hähnle, C Viljoen; (V) Data analysis and interpretation: All authors; (VI) Manuscript
writing: All authors; (VII) Final approval of manuscript: All authors.
#
These authors contributed equally to this work.
Correspondence to: Dr. Charle Viljoen. Division of Cardiology, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa.
Email: charle.viljoen@uct.ac.za.
Abstract: Peripartum cardiomyopathy (PPCM) is an idiopathic dilated cardiomyopathy, in which
previously healthy women present with heart failure secondary to left ventricular (LV) systolic dysfunction
during the last months of pregnancy or up to 5 months postpartum. PPCM occurs worldwide. The incidence
seems to be increasing, possibly due to increasing awareness of the condition and diagnosis thereof. Women
diagnosed with PPCM present with symptoms and signs of heart failure, thromboembolism or arrhythmia.
Although the incidence of arrhythmias in this condition is not well documented, patients with PPCM often
have rhythm disturbances. Indeed, life-threating arrhythmias contribute significantly to sudden cardiac death
(SCD) in this population, especially when patients have poor systolic function. In this review, we summarize
the evidence on atrial and ventricular arrhythmias in PPCM, as detected by various diagnostic modalities.
Furthermore, we summarize the management of arrhythmias in PPCM, as recommended by contemporary
guidelines.
Keywords: Ambulatory electrocardiographic monitoring (AECG); arrhythmia; cardioverter-defibrillator;
electrocardiogram (ECG); peripartum cardiomyopathy (PPCM)
Submitted Apr 24, 2019. Accepted for publication May 20, 2019.
doi: 10.21037/cdt.2019.05.03
View this article at: http://dx.doi.org/10.21037/cdt.2019.05.03
Introduction
Peripartum cardiomyopathy (PPCM) is a rare, idiopathic
dilated cardiomyopathy, presenting with heart failure
secondary to left ventricular (LV) systolic dysfunction
towards the end of pregnancy or up to five months
postpartum (1). PPCM occurs worldwide. However, the
incidence of PPCM varies between countries as well
as between ethnic groups (2-5). Incidence seems to be
increasing, possibly due to increased awareness of the
condition and the diagnosis thereof (6).
Even though the exact pathophysiology of PPCM is
unknown, various mechanisms have been proposed to
© Cardiovascular Diagnosis and Therapy. All rights reserved.
contribute to the pathogenesis. These include nutritional
factors, viral infections, inflammatory and autoimmune
processes, as well as a familial and genetic predisposition (7).
Recent studies suggest that the nursing hormone prolactin
is crucially involved in the pathogenesis of PPCM (8).
LV recovery in PPCM remains markedly heterogenous
and differs significantly between countries and ethnicities.
Recent reports suggest that approximately 45–75% of
all affected women recover their LV function after 6
to 12 months. However, lower rates of recovery have
been reported in developing countries (9). Although LV
recovery predominantly occurs within the first 6 months
after diagnosis, it has been shown to continue beyond
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326
Hoevelmann et al. Detection and management of arrhythmias in PPCM
of life-threatening ventricular arrhythmias, which may lead
to SCD if left untreated (17,18). In this regard, Goland et al.
estimated that in the USA 1 in 4 women with PPCM suffer
cardiac arrest secondary to ventricular tachyarrhythmia (14).
In this review, we explore the methods of detecting and
diagnosing arrhythmias in PPCM, which may ultimately
assist in the risk stratification and in decision of appropriate
therapy. We also summarise the management of arrhythmias
in PPCM, as recommended by contemporary guidelines.
12-lead electrocardiogram (ECG)
Figure 1 The 12-lead electrocardiogram forms part of the routine
work-up of all patients who are diagnosed with peripartum
cardiomyopathy. The test is non-invasive, widely available,
inexpensive and easily performed.
12 months (10). African ethnicity seems to have an impact
on the outcome of patients with PPCM, as it has been
shown that women of African ethnicity present with a more
severely reduced LV ejection fraction (LVEF) and recover
less frequently than their non-African counterparts (11).
Sudden cardiac death (SCD), which is often the result
of a preceding episode of a ventricular tachyarrhythmia, is
responsible for about one-third of deaths in non-ischaemic
cardiomyopathies (NICM) (12). In PPCM, SCD contributes
to 25–39% of all-cause mortality (13,14), suggesting that
arrhythmias are not uncommon in this population (15).
Indeed, in a retrospective analysis of 9,841 hospital
admissions for PPCM in the USA, arrhythmias were
reported to have occurred in 18.7% of cases. In this study,
ventricular tachycardia (VT)—seen in 4.2% of patients—
was the most common arrhythmia, followed by atrial
fibrillation (1.3%) and ventricular fibrillation (VF) (1%) (16).
However, literature on the exact underlying mechanisms
of SCD in the course of PPCM is scarce, particularly
that pertaining to the burden of malignant ventricular
arrhythmias. Nevertheless, studies show that reduced LVEF
in the early stages of PPCM is accompanied by a high risk
© Cardiovascular Diagnosis and Therapy. All rights reserved.
The 12-lead ECG (Figure 1) is an inexpensive, easily
performed and widely available clinical investigation, which
forms part of the routine work-up of patients who present
with cardiovascular disease (Table 1). Indeed, the ECG is
recommended in all patients who present with a suspected
diagnosis of PPCM (27). The 12-lead ECG is invaluable for
the analysis of waveform abnormalities that are associated
with chamber enlargement (such as atrial dilatation or
ventricular hypertrophy), conduction delays (such as bundle
branch blocks) and repolarization abnormalities (such as T
wave inversion and prolonged QT intervals) (28). The 12lead ECG is also indispensable as a diagnostic modality of
brady- and tachyarrhythmias.
Although there is no specific electrocardiographic
abnormality that is pathognomonic of PPCM, women
with PPCM rarely have a normal ECG (19,20). The most
common waveform abnormalities seen on the 12-lead ECG
include non-specific T wave changes (i.e., T wave inversion)
and prolongation of the QTc interval (Table 2) (19-21,29,33).
T wave inversion at the time of diagnosis is associated with
poor systolic function (LVEF <35%) (20). Furthermore,
an upright T wave in lead aVR has recently been shown
to be a predictor of adverse outcome in PPCM (31). In
another prospective study, QTc prolongation (i.e., corrected
QT interval >460 ms) on the initial ECG was shown to be
an independent predictor of poor long-term outcome in
PPCM. In fact, all patients who died in this study initially
presented with a prolonged QTc interval (20). Care should
therefore be taken when treating patients with PPCM to
avoid drugs that are associated with QT prolongation.
Despite the QRS complex of patients with PPCM being
marginally wider than that of a healthy population (21),
it is typically narrow (i.e., QRS <110 ms) (20,22,29). As
opposed to other forms of dilated cardiomyopathy where
bundle branch blocks are encountered in 25–30% of
patients (34,35), bundle branch blocks are seldom found in
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Table 1 Comparison of devices used to diagnose arrhythmias, with supporting evidence of the atrial and ventricular arrhythmias found in PPCM
ECG
12-lead ECG
Ambulatory ECG monitoring
Continuous
monitoring (e.g.,
Holter ECG)
Intermittent
monitoring (e.g.,
implantable
loop recorder)
Cardioverter-defibrillator devices
Wearable cardioverterdefibrillator (WCD)
Implantable
cardioverterdefibrillator (ICD)
Length of
recording
10 seconds
Usually 24 or
48 hours, though
newer devices can
monitor up to
60 days
Up to
three years
(depending on
the battery leave
of the device)
As long as wearable
cardioverter-defibrillator
is worn
As long as battery
life of implanted
cardioverterdefibrillator lasts
Purpose of
device
Diagnostic
Diagnostic
Diagnostic
Therapeutic, but also
provides diagnostic
information
Therapeutic, but
also provides
diagnostic
information
Application
Non-invasive
Non-invasive
Invasive
Non-invasive
Invasive
Arrhythmias
diagnosed
Whereas sinus tachycardia
is common at time of
diagnosis, sinus arrhythmia
becomes more prevalent
at follow up (19-21).
While sinus tachycardia
is associated with poor
outcome, sinus arrhythmia
predicts freedom of death
and readmission to hospital
(20). Prolonged QTc at time
of diagnosis is associated
with poor outcome
(thought to be related to
increased risk of ventricular
arrhythmias) (20). Atrial
fibrillation and LBBB, which
are more prevalent in other
forms of non-ischaemic
dilated cardiomyopathy,
seem to be uncommon
in PPCM (20,22,23). AV
block SVT and VT are rarely
diagnosed by 12-lead ECG
in PPCM (19-21)
Literature confined
to a single study on
19 patients: sinus
tachycardia found
in 89% and nonsustained ventricular
tachycardia in 21%
of patients (24)
To the best of
our knowledge,
there is no
literature
available on
external or
implantable
loop recorders
in PPCM
WCD for primary
prevention of SCD
used in patients with
LVEF <35%: though
Saltzberg et al. (25)
detected no arrhythmias,
Duncker et al. (17,18)
reported in two studies
that the WCD could
detect non-sustained
ventricular tachycardia
and ventricular fibrillation,
which were successfully
aborted by the WCD
ICD for primary
prevention of SCD
used in patients
with LVEF <35%.
A single study
reports that
37% of patients
had appropriate
shocks (26)
ECG, electrocardiogram; LBBB, left bundle branch block; LVEF, left ventricular ejection fraction; PPCM, peripartum cardiomyopathy; QTc,
corrected QT interval; SCD, sudden cardiac death; SVT, supraventricular tachycardia; VT, ventricular tachycardia.
© Cardiovascular Diagnosis and Therapy. All rights reserved.
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Hoevelmann et al. Detection and management of arrhythmias in PPCM
328
Table 2 Summary of prospective and retrospective studies diagnosing arrhythmias in PPCM
Author
Main finding about arrhythmias in PPCM
Arrhythmias diagnosed with
Year
Country
N
Diao et al. (24)
2004
Senegal
19
24-hour Holter found sinus tachycardia in 89% of
patients, non-sustained VT in 21%
Duncker
et al. (17)
2014
Germany
12
9 of 12 patients had LVEF <35%; in 3 of 7 patients
with WCD, ventricular tachyarrhythmias were
detected and successfully treated by the device
X
Duncker
et al. (18)
2017
Germany
49
All patients had LVEF <35% and fitted with WCD.
Of these 12% had ventricular tachyarrhythmias with
appropriate therapy by the device
X
Hoevelmann
et al. (20)
2019
SA
66
Prolonged QTc and sinus tachycardia were
independent predictors of poor outcome. Sinus
arrhythmia was associated with event-free survival
X
Honigberg
et al. (29)
2019
USA
88
Left atrial enlargement on ECG predicted poor longterm outcome
X
Karaye et al. (21)
2016
Nigeria
54
54 patients with PPCM were compared with 77
healthy controls. QTc prolongation was found in
almost 25% of those with PPCM
X
Ntusi et al. (23)
2015
SA
30
30 patients with PPCM were compared to
53 patients with hypertensive heart failure of
pregnancy. Atrial fibrillation was found in 10% of
patients with PPCM
X
Pillarisetti
et al. (30)
2014
USA
100
2 patients died from arrhythmia-related causes
(unspecified)
?
Saltzberg
et al. (25)
2012
USA
107
107 patients with PPCM were compared with 109
other non-dilated ischaemic cardiomyopathies.
None of the patients with PPCM experienced any
arrhythmic events
Sliwa et al. (22)
2017
SA
411
Left bundle brunch block occurred in 9.3% of
patients with PPCM
X
Tibazarwa
et al. (19)
2012
SA
78
Sinus tachycardia was found in 45% of PPCM
patients, left bundle branch block in 5%, PVC in 4%
X
ECG
Holter
ILR
WCD
ICD
Prospective studies
X
X
Retrospective studies
De Benedetti
Zunino et al. (26)
2014
USA
19
ICD for primary prevention: 37% of patients had
appropriate shocks
Ekizler et al. (31)
2019
Turkey
82
An upright T wave in lead aVR on ECG was
associated with poor outcome
X
Goland et al. (14)
2009
USA
46
15% had ventricular tachyarrhythmias requiring ICD;
7% had bradyarrhythmias requiring pacemakers
?
Pakistan
45
6.6% of patients presented with ventricular
tachycardia
?
71
QTc prolongation was found in 47% of PPCM
patients
X
Laghari et al. (32) 2013
Li et al. (33)
2016
China
Mallikethi-Reddy
et al. (16)
2017
USA
9841 Arrhythmias were present in 18.7% of hospitalized
PPCM cohort. 4.2% had VT, 2.2% had sudden
cardiac death
X
?
ECG, electrocardiogram; ICD, implantable cardioverter-defibrillator; ILR, implantable loop recorder; LVEF, left ventricular ejection fraction;
PPCM, peripartum cardiomyopathy; PVC, premature ventricular complex; QTc, corrected QT interval; VT, ventricular tachycardia; WCD,
wearable cardioverter-defibrillator; SA, South Africa; USA, the United States of America.
© Cardiovascular Diagnosis and Therapy. All rights reserved.
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329
include the 12-lead ECG as the only method of diagnosing
arrhythmias in PPCM.
Ambulatory ECG monitoring
Figure 2 The Holter ECG is a form of continuous ambulatory
ECG monitoring, which typically records data for 24 to 48 hours.
The Holter ECG has a good yield of arrhythmias, but only if they
occur frequently. ECG, electrocardiogram.
PPCM (20,22). Though the literature on bradyarrhythmias
in PPCM is scarce, it has been reported that up to 7% of
patients require permanent pacing (14).
The majority of patients with PPCM present with sinus
rhythm. Though sinus tachycardia (i.e., sinus rhythm with
heart rate >100 beats per minute) is frequently found at the
time of diagnosis, there seems to be a significant reduction
in heart rate between the initial presentation with PPCM
and subsequent follow-up visits (20,22). Sinus arrhythmia
(i.e., sinus rhythm with variable RR intervals), which occurs
in about one third of patients at the time of their PPCM
diagnosis, becomes more prevalent at long-term followup (20). Whereas sinus tachycardia at the time of diagnosis
has been shown to be an independent predictor of poor
long-term outcome in PPCM, sinus arrhythmia seems
to be associated with event-free survival (i.e., no death or
readmission to hospital) (20).
Although atrial fibrillation is more prevalent in PPCM
than in hypertensive heart failure of pregnancy (23), it
remains relatively uncommon (20,31). Supraventricular and
ventricular tachycardia are rarely are rarely recorded by the
12-lead ECG in patients with PPCM (16,20,29). However,
as the 12-lead ECG usually only records a ‘snapshot’ of 10
seconds, it is thought that the true incidence of these bradyand tachyarrhythmias is underestimated by studies that
© Cardiovascular Diagnosis and Therapy. All rights reserved.
Ambulatory electrocardiographic monitoring (AECG) is
essential in the work-up of arrhythmias, especially when
arrhythmias and/or symptoms are paroxysmal (36). Because
ambulatory ECG monitoring extends the recording time
significantly from the 10-second long 12-lead ECG, it
allows for a more accurate characterization of cardiac
activity during ordinary daily activities and increases the
yield of arrhythmias (36,37).
AECG devices can be categorized according to whether
they record continuously (over a shorter period of time) or
intermittently (with brief recordings over an extended period
of time) (37). Continuous AECG monitoring is commonly
referred to as “Holter” ECG monitoring (Figure 2).
Holter monitors are non-invasive and are usually worn for a
period of 24 to 48 hours (38,39), though newer technology
allows monitoring for up to 60 days (40). Holter monitoring
is more likely to detect arrhythmias if symptoms and/
or arrhythmias occur frequently. However, intermittent
AECG monitoring allows for longer periods of surveillance.
Intermittent AECG devices include external loop recorders
(i.e., an adhesive electrode that is usually worn for up to
two months) and implantable loop recorders (ILR) (i.e.,
a monitoring device that is implanted subcutaneously)
(Figure 3). Due to recent advances, newer ILR devices are
smaller in size and have improved algorithms for arrhythmia
detection (Figure 4) (41). Although loop recorders are
worn continuously, they only record when the device
detects an arrhythmia or when patients activate the device
when symptomatic. Because of their extended monitoring,
loop recorders are more likely to detect intermittent or
infrequent arrhythmias (40).
Literature on ambulatory ECG monitoring in PPCM is
limited to a single study by Diao et al., who prospectively
studied the detection of arrhythmias by 24-hour Holter in a
cohort of 19 patients with PPCM (24). Though infrequent
symptoms impede the detection rate of arrhythmias by
Holter monitoring (38), the 24-hour Holter recorded VT
in 4 of 19 the patients (21%) in this cohort (24).
Similarly, the 12-lead ECG does not often record
premature atrial or ventricular contractions in PPCM (20),
but these were more frequently diagnosed by Holter
monitoring, i.e., premature atrial contractions in 21% and
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Hoevelmann et al. Detection and management of arrhythmias in PPCM
330
premature ventricular contractions in 36.8% of patients in
the study by Diao et al. (24). The significance of detection
of premature complexes by AECG in PPCM has not yet
been studied.
In addition to the detection of arrhythmias, Holter
monitoring also provides useful information regarding heart
rate. The ambulatory monitoring device’s software typically
provides the average heart rate over the monitoring period,
as well as the minimum and maximum heart rates, and the
time spent in bradycardia and tachycardia over the period that
the Holter ECG was worn by the patient (36,40). In their
study, Diao et al. demonstrated that Holter monitoring was
more sensitive at diagnosing sinus tachycardia: the 24-hour
Holter detected sinus tachycardia in 89.4% of patients with
PPCM, whereas the 12-lead ECG recorded sinus tachycardia
in only 68.4% of patients from the same cohort (24).
Diagnosing sinus tachycardia may have implications on risk
stratification of patients with PPCM, as sinus tachycardia
on the 12-lead ECG has been shown to be associated with
poor long-term outcome (20).
As SCD significantly contributes to mortality in
PPCM, and recognizing the shortage of literature on
ECG monitoring beyond that of the 12-lead ECG, future
research should include AECG in prospective studies to
establish the true incidence of arrhythmias in PPCM. At
present, there is an ongoing study with an ILR for the early
identification of patients with PPCM at risk for arrhythmic
events.
Prevention and treatment of arrhythmias in
PPCM
Figure 3 The implantable loop recorder (ILR) is a form of
intermittent ambulatory ECG monitoring, which is implanted
subcutaneously and can record up to 3 years’ data. ILRs should be
considered when arrhythmias are thought to occur infrequently and
when the Holter ECG is non-revealing. ECG, electrocardiogram.
The management of arrhythmias in PPCM requires
the concurrent treatment of systolic heart failure. The
essential therapies for acute PPCM can be summarized
with the acronym ‘BOARD’ (Bromocriptine, Oral heart
failure therapies, Anticoagulants, vasoRelaxing agents, and
Diuretics) (42). As outlined in the European Society of
Cardiology (ESC) Guidelines (43), therapeutic management
Chart speed 25.0 mm/sec
ECG filter on
ECG reveal
(0.1 mV)
Markers
Interval (ms)
VT detected
Figure 4 An episode of non-sustained ventricular tachycardia (VT) as recorded by an implantable loop recorder in a patient with peripartum
cardiomyopathy. The non-sustained VT is recognised by the wide QRS complexes with short RR intervals (on the left). The last two beats (on
the right) represent sinus rhythm with narrow QRS complexes.
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Cardiovascular Diagnosis and Therapy, Vol 10, No 2 April 2020
of acute PPCM differs depending on the severity of
heart failure, and whether the patient presents during the
antepartum or postpartum period.
In the antepartum period, patients with PPCM are
best co-managed by a team consisting of cardiologists
and obstetricians to ensure the health of the mother
and the foetus. Due to the risk of fetotoxic side-effects,
treatment such as angiotensin converting enzyme
inhibitors (ACE-i), angiotensin II receptor blockers (ARB),
angiotensin receptor-neprilysin inhibitors (ARNI) and
mineralocorticoid receptor antagonists (MRA) should
rather be avoided during pregnancy. However, hydralazine
and nitrates have been shown to be safer in the antepartum
period instead. Loop diuretics could be considered for the
treatment of pulmonary congestion and vaginal delivery
should be pursued in patients without cardiopulmonary
distress. Beta-blockers (i.e., metoprolol as preferred agent)
could be initiated but the doses should be titrated with
caution (27,43).
After delivery, treatment of PPCM should be aligned
with contemporary acute and chronic heart failure
guidelines (27,44-46). First-line therapy should consist of
a combination of beta-blockers, ACE-i/ARBs, an MRA
and diuretics. The benefits of using digoxin in addition to
first-line therapy remains controversial (47). The use of the
prolactin-blocker, bromocriptine, should be considered, and
should be accompanied by anticoagulants to reduce the risk
of thromboembolic events (27).
As sinus tachycardia is associated with adverse outcome
in PPCM, ivabradine may be considered in addition to firstline therapy in patients with an increased resting heart rate
who are not pregnant or breastfeeding (27,43). However,
evidence supporting the use of ivabradine in this setting
is currently limited to a single retrospective observational
study (48).
When a patient with PPCM develops atrial fibrillation,
beta-blockers and/or digoxin could be considered. Because
amiodarone is associated with foetal side effects, it should be
reserved for emergency situations. Electrical cardioversion
is only indicated in the setting of haemodynamic instability
(43,49).
Patients with PPCM who present with sustained VT
or VF should be electrically cardioverted or defibrillated
without delay (43,50). Intravenous amiodarone may be
considered in patients with refractory VT (43,50).
© Cardiovascular Diagnosis and Therapy. All rights reserved.
331
Implantable cardioverter-defibrillator (ICD)
Patients with severely impaired systolic function (LVEF
<35%) are at high risk of life-threatening ventricular
arrhythmias, which could result in SCD (51,52). The current
ESC guidelines on acute and chronic heart failure therefore
recommend ICD implantation as primary prevention
in patients with severely reduced ejection fraction (i.e.,
LVEF <35%) despite optimal medical therapy (OMT) and
as secondary prevention in patients with a documented
or survived episode of ventricular arrhythmias (44).
Indeed, in a retrospective analysis of 19 patients with
PPCM that received ICDs for primary prevention of SCD,
36.8% received appropriate shocks (26). However, given
the high LV recovery rate associated with PPCM, the
decision to implant an ICD should be made with caution.
Early implantation of ICDs is often not justifiable in this
young population and it has therefore been suggested that,
in PPCM, they should be reserved for patients without LV
recovery (27,43).
Wearable cardioverter-defibrillator (WCD)
A WCD (LifeVest®, Zoll, Pittsburgh, PA, USA) is a safe
and non-invasive device, which can protect from SCD
during a suspected, vulnerable period for arrhythmic events.
The vest continuously analyzes the heart rhythm and
delivers biphasic shocks once a life-threatening arrhythmia
is detected (53). Although these devices primarily have a
therapeutic indication, they also offer important diagnostic
information. A recent study from Germany evaluated the
use of a WCD for prevention of SCD in PPCM in PPCM
(Figure 5). During a cumulated wearing time of 932 days,
four adequate shocks were delivered by the WCD for VF
to the seven patients with newly diagnosed PPCM and
severely reduced ejection fraction (LVEF <35%) who opted
to wear the WCD (17). In a subsequent study on 49 patients
with newly diagnosed PPCM and severely reduced ejection
fraction (LVEF <35%), the WCD recorded ventricular
arrhythmias in six patients (12%), i.e., five episodes of
VF, two sustained VTs and one non-sustained VT. All
episodes of VF were terminated by a WCD shock and no
inappropriate shocks occurred during the study period.
These ventricular arrhythmias occurred between 40 and
165 days after the diagnosis of PPCM was made and the
WCD was fitted (18).
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332
Hoevelmann et al. Detection and management of arrhythmias in PPCM
Figure 5 The wearable cardioverter-defibrillator (WCD) is a non-
Figure 6 The implantable cardioverter defibrillator (ICD) delivers
invasive device that is worn by patients with LVEF <35%. The
shocks when life-threatening arrhythmias are detected. In PPCM,
WCD is able to deliver biphasic shocks when a life-threatening
ICD therapy is best reserved for patients without LV recovery (usually
arrhythmia is detected and could be used as a ‘bridging’ strategy
LVEF <35%) at follow-up. PPCM, peripartum cardiomyopathy; LV,
during the first 6 months of vulnerability to sudden cardiac death
left ventricular; LVEF, left ventricular ejection fraction.
in PPCM, before a final decision towards implantable cardioverterdefibrillator (ICD) is made. PPCM, peripartum cardiomyopathy;
LVEF, left ventricular ejection fraction.
Despite the limited evidence on WCD in PPCM,
the current European and American guidelines suggest
consideration of these devices for high-risk patients with
LVEF ≤35% as a ‘bridging strategy’ to LV recovery (27,43).
Bearing in mind that a WCD could save the life of a young
mother, the high costs of the vest could be justifiable;
especially given its reusability. ICD implantation (Figure 6)
and cardiac resynchronization therapy (CRT) [for patients
with LBBB (left bundle branch block) and QRS duration
≥130 ms] should be reserved for patients with persistent LV
dysfunction (LVEF <35%) despite OMT at 6 to 12 months
after presentation (43,54).
Conclusions
The 12-lead ECG commonly shows repolarisation changes
such as T wave inversion and QT prolongation. However,
arrhythmias other than sinus tachycardia are infrequently
detected by the 12-lead ECG. Though there is limited
literature on ambulatory ECG monitoring in PPCM, it has
© Cardiovascular Diagnosis and Therapy. All rights reserved.
been shown that life-threatening ventricular arrhythmias
might be relatively common in the early phase of the
condition. Because LV recovery is common in PPCM, the
decision to insert an ICD in a patient who initially presents
with an LVEF <35% could be delayed, and a WCD could
be considered instead. The WCD could be used as ‘bridging
therapy’ until the LVEF is re-evaluated at follow up. ICDs
are best reserved for patients with PPCM without LV
recovery after 6 months.
Acknowledgments
We would like to thank Ms Helene-Marie Guillaume for
designing the figures, as well as Associate Professor Ashley
Chin from Groote Schuur Hospital in Cape Town, Mrs
Sylvia Dennis from the Hatter Institute for Cardiovascular
Research in Africa, and Dr. Nick Simpson at New Somerset
Hospital in Cape Town, for their help in preparing the
manuscript.
Funding: The Hatter Institute for Cardiovascular Research
in Africa receives research funding and support from the
University of Cape Town, the Medical Research Council
(MRC) of South Africa and the South African National
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Cardiovascular Diagnosis and Therapy, Vol 10, No 2 April 2020
333
Research Foundation (NRF).
5.
Footnote
Provenance and Peer Review: This article was commissioned
by the Guest Editor (Ntobeko A. B. Ntusi) for the series
“Cardiovascular Diseases in Low-and Middle-Income
Countries” published in Cardiovascular Diagnosis and
Therapy. The article was sent for external peer review
organized by the Guest Editor and the editorial office.
6.
Conflicts of Interest: All authors have completed the ICMJE
uniform disclosure form (available at http://dx.doi.
org/10.21037/cdt.2019.05.03). The series “Cardiovascular
Diseases in Low-and Middle-Income Countries” was
commissioned by the editorial office without any funding
or sponsorship. The authors have no conflicts of interest to
declare.
8.
Open Access Statement: This is an Open Access article
distributed in accordance with the Creative Commons
Attribution-NonCommercial-NoDerivs 4.0 International
License (CC BY-NC-ND 4.0), which permits the noncommercial replication and distribution of the article with
the strict proviso that no changes or edits are made and the
original work is properly cited (including links to both the
formal publication through the relevant DOI and the license).
See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
2.
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Cite this article as: Hoevelmann J, Hähnle L, Hähnle J,
Sliwa K, Viljoen C. Detection and management of arrhythmias
in peripartum cardiomyopathy. Cardiovasc Diagn Ther
2020;10(2):325-335. doi: 10.21037/cdt.2019.05.03
© Cardiovascular Diagnosis and Therapy. All rights reserved.
Cardiovasc Diagn Ther 2020;10(2):325-335 | http://dx.doi.org/10.21037/cdt.2019.05.03