Author + information
- Dennis M. McNamara, MD, MS∗ (, )
- Uri Elkayam, MD,
- Leslie Cooper, MD,
- James D. Fett, MD,
- IPAC Investigators
- ↵∗Heart and Vascular Institute, University of Pittsburgh Medical Center, 566 Scaife Hall, 200 Lothrop Street, Pittsburgh, Pennsylvania 15213
We appreciate the work of Drs. Hilfiker-Kleiner and colleagues on European and South African cohorts with peripartum cardiomyopathy. They have raised important questions and we are happy to clarify. First, the entry criteria for women in the IPAC (Investigations of Pregnancy-Associated Cardiomyopathy) study (1) were based on the clinical assessment of left ventricular ejection fraction (LVEF) at their local institutions, and all subjects met the entry criteria of a local clinical LVEF estimated at <0.45. However, we had the advantage of an experienced core echocardiography laboratory, which reviewed echocardiograms in a blinded fashion and directly calculated LVEFs. All figures and analyses for our publication used the values provided by the core laboratory. As in most heart failure clinical trials, these core calculations of LVEF tended to be higher than the local clinical assessment.
The referenced European registry (2) does not mention any core laboratory assessment of LVEF and, we assume, utilized the local clinical value for their analysis. If this is the case, then the LVEFs at entry of these 2 cohorts are very comparable. Recovery in the IPAC study to an LVEF >0.50 was evident in 72% of subjects; applying the standard used in the European registry to our study demonstrates recovery to an LVEF >0.55 in 52% of IPAC subjects, again comparable to the 47% of women in the European registry. The 2 cohorts are similar in their outcomes and contemporary therapy with the exception that bromocriptine was used in 67% of the women of the European registry, but only 1% of the IPAC cohort. Importantly our studies show that severe LV dysfunction and greater remodeling at study entry were associated with less recovery.
In terms of breastfeeding, we agree that the potential transmission of medication must be taken into account when making decisions in the best interests of the mother and child, and we do not suggest in our study that breastfeeding is “safe.” However, we specifically note that there was no evidence of an adverse impact of breastfeeding on myocardial recovery because the mean LVEF at 12 months for the 15 women who breastfed was 0.57 ± 0.04. These women tended to be less ill (80% were New York Heart Association functional class I or II), and we do not have data on how long they breastfed. Concerns about the metabolic demands on maternal health or potential maternal transmission of medications to the child frequently leads to a recommendation against breastfeeding, particularly in women with more severe heart failure. However, our study does not provide any evidence to support a recommendation against breastfeeding based on a theoretical impact on recovery. Although we appreciate the small pilot study referenced (3), the hidden costs of a prohibition of breastfeeding in terms of neonatal health and development remain a concern that should be considered in making the best recommendation for mother and child.
Please note: The authors have reported that they have no relationships relevant to the contents of the paper to disclose.
- 2016 American College of Cardiology Foundation
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