Postpartum Cardiomyopathy – A Cardiac Emergency for Gynecologists, General Practitioners, Internists, Pulmonologists, and Cardiologists: In reply

by Prof. Dr. Denise Hilfiker-Kleiner, PhD, Dr. med. Elisabeth Schieffer, PD Dr. med. Gerd Peter Meyer, Dr. med. Edith Podewski, Prof. Dr. med. Helmut Drexler in volume 44/2008

For reasons of limited space, we cannot respond to all aspects that Dr Swalve-Bordeaux raised in her letter and therefore refer interested readers to our publications (1, 2, 3). However, we wish to emphasize, that in severe postpartum cardiomyopathy with a high case fatality and a high risk of irreversible cardiac failure, immediate therapy with beta blockers and ACE inhibitors is indicated. ACE inhibitors can be passed to the neonate in breast milk. Cessation of breast feeding is thus indicated; quite apart from the fact that in many cases the women are in severe cardiac failure needing intensive care and are therefore hardly able to breast feed. In a scenario of 15–20% mortality and 50% persistent symptoms of cardiac failure (complete recovery occurs in only 30%), the main focus should be on treating the mother, aiming on her recovery to ensure that a good bond between mother and child can develop over the longer term.

If weaning is required in this situation for clinical-pharmacological reasons, then bromocriptine is the medication of choice. Our observations imply that prolonged treatment with bromocriptine over 2 months in addition to standard therapy of heart failure results in a substantial recovery in cardiac function. We now have data from 11 patients with a mean rise in ejection fraction of 25% to 52% after 6 months. In 10 patients who only obtained standard therapy of heart failure without bromocriptine, the mean ejection fraction had risen from 23% to 26.5%. Colleagues at the Charité in Berlin and Göttingen University Hospital were so impressed with our results that they now apply the new option in patients with severe postpartum cardiomyopathy, and very successfully so. We emphasized in our article—and we repeat this here—that at this point in time, additional treatment with bromocriptine is not established, but in our opinion, and in agreement with all cardiology experts, it is justified to test this new therapeutic principle in a randomized multicenter study. This clinical trial will start in early 2009.

Prof Stoffregen relies on initial studies of cardiomyopathy in drawing up the clinical practice and pathological cardiac finding in analogy to our characterization. However, he did not provide any "compulsory proof" for his personal theory of the pathomechanism of this disorder. There is no consistent histopathological documentation for embolization of chorionic villi in the heart, nor are other organs affected accordingly. The—rather heroic—hysterectomy prevents with absolute certainty another pregnancy and the associated risk of cardiomyopathy.

Which patient or treating physician would prefer for the treatment of severe postpartum cardiomyopathy the extirpation of the uterus, whose effectiveness has never been studied, to bromocriptine treatment, whose initial results have been encouraging?
DOI: 10.3238/arztebl.2009.0191b


Prof. Dr. med. Helmut Drexler
Klinik für Kardiologie und Angiologie
Medizinische Hochschule Hannover
Carl-Neuberg-Str. 1
30625 Hannover, Germany
[e-mail]

Conflict of interest statement
The authors of all letters and of the reply declare that no conflict of interest exists according to the guidelines of the International Committee of Medical Journal Editors.

References

1. Hilfiker-Kleiner D, Kaminski K, Podewski E et al.: A cathepsin D-cleaved 16 kDa form of prolactin mediates postpartum cardiomyopathy. Cell 2007; 128: 589–600.

2. Hilfiker-Kleiner D, Meyer GP, Schieffer E et al.: Recovery from postpartum cardiomyopathy in 2 patients by blocking prolactin release with bromocriptine. J Am Coll Cardiol 2007; 50: 2354-5.

3. Hilfiker-Kleiner D, Sliwa K, Drexler H: Peripartum cardiomyopathy: recent insights into its pathophysiology. Trends in Cardiovasc Med 2008; 18: 173–9.

4. Hilfiker-Kleiner D, Schieffer E, Meyer GP, Podewski E, Drexler H: Postpartum cardiomyopathie: a cardiac emergency for gynecologists, general practitioners, internists, pulmonologists and cardiologists. [Die postpartale Kardiomyopathie. Ein kardiologischer Notfall für Gynäkologen, Hausärzte, Internisten, Pneumologen und Kardiologen]. Dtsch Arztebl Int 2008; 105(44): 751–6.