|Professor Karen Sliwa-Hahnle|
Joint chairperson of the PPCM (Peripartum Cardiomyopathy) Executive Committee
University of Cape Town, South Africa
“The Study Group on Peripartum Cardiomyopathy was formed by the ESC in 2010 with the objective of bringing together specialists from a variety of disciplines to facilitate better understanding and management of women with Peripartum Cardiomyopathy (PPCM). Our core group of 20 members includes basic researchers, cardiologists, intensivists and gynaecologists.
PPCM is a disorder where heart failure symptoms occur secondary to left ventricular systolic dysfunction towards the end of pregnancy or in the early postpartum period. The incidence has been shown to vary according to race and region: PPCM is known to affect one in 2200-3000 women in the US, one in 1000 in South Africa and one in 300 in Haiti. That no data are currently available for Europe underlines how little is known about this life threatening condition which can rapidly progress to end stage heart failure.
The exact cause of PPCM is unknown with potential mechanisms proposed including nutritional deficiencies, genetic disorders, viral or autoimmune causes, hormonal imbalances, inflammation and apoptosis. Multiple factors, it has been suggested, are able to induce PPCM which merge in a common downstream mechanism with enhanced oxidative stress and cleavage of the pregnancy hormone prolactin into an angiostatic N-terminal prolactin fragment which causes massive endothelial damage and myocardial dysfunction. In small clinical studies and registries blocking prolactin with the dopamine receptor 2D agonist bromocriptine has been shown to exert beneficial effects.
The activities of the study group have included publishing two position papers in the European Journal of Heart Failure (one in press), contributing to more than 10 peer review papers, and producing a less restrictive definition of PPCM that does not exclude women who present more than six months post partum. In 2012 working with the ESC EurObservational program (EORP), the study group initiated a large international registry on PPCM which we hope will help to broaden understanding with regard to aetiology and geographical differences, and provide important new information to optimize treatment strategies. The secondary aims include evaluating how recommendations are currently followed and identifying parameters that will serve as diagnostic and prognostic markers.
We would like to encourage clinicians from anywhere in the world who have patients with PPCM and access to echocardiography to enter them into our registry. To date we have enrolled 160 patients, but our aim is to include 1000 women and collect data on maternal outcomes at six and 12 months.
While investigators participate on a voluntary basis and are responsible for obtaining the approval of the local ethics board a dedicated team of data specialists are on hand at ESC Heart House to assist on entering cases and providing guidance. An n additional facility is that clinicians participating in the registry are able to seek advice on the management of PPCM by contacting study group members by email or telephone.
Since many women with PPCM achieve normal heart function within a short time, we believe that understanding the factors that contribute to their fast recovery could also facilitate improvements in the management of patients with other cardiac conditions.”
Click here for further information on the registryClick here for further information on the committee
|Professor Aldo Pietro Maggioni|
Secretary of the HFA from ANMCO (National Association of Hospital Cardiologists) Research Center, Florence, Italy
“AIMHIGH is a European quality improvement programme that is being developed by the Heart Failure Association (HFA) to reduce the gap between the current ESC guidelines and what actually takes place in routine clinical practice.
Over the last 20 years despite significant advances in diagnosis and therapy heart failure patients continue to have poor long-term prognosis. Clinical destabilizations leading to hospitalization are associated with hemodynamic and neuro-hormonal alterations, which can contribute to progressive ventricular dysfunction and dilation, mitral regurgitation, increased wall stress, and progressive myocyte loss as a result of apoptosis and necrosis. Registries and surveys have revealed that current guidelines are infrequently adopted, which raises serious concerns since studies have shown that adherence to guidelines is associated with improvements in survival and reductions in hospitalisations.
First we are evaluating how the ‘Get With The Guidelines’® (GWTG) methodology, pioneered by the American Heart Association, will work in a European setting. The GWTG in-hospital programme, aimed to promote consistent adherence to the latest scientific treatment guidelines, provides patient-specific guideline recommendations, webinars aimed at improving quality of cardiovascular care and on-demand reports for each institution tracking performance. A number of published studies have demonstrated GWTG’s success in achieving significant patient outcome improvements, including reductions in 30-day readmissions.
Our pre-pilot observational study, launched by the HFA in December 2013, is checking the feasibility of the methodology in Italy, Poland, France and Greece. Each country has three participating centres, which will be coordinated by Attikon University Hospital, Athens, and required to fill in case report forms on consecutive patients admitted to the hospital six months. We’ve estimated that we’ll need to enrol at least 500 patients to get sufficient information on the different subgroups, i.e. patients with preserved ejection fraction, patients with different clinical profiles at hospital admission, and patients with COPD or diabetes. For each patient information on demographic characteristics, risk factors for cardiovascular diseases, co-morbidities, precipitating factors of acute heart failure, clinical signs and symptoms, biohumoral profiles, use of pharmacological treatments, use of non pharmacological treatments and use of invasive/non invasive diagnostic procedures will be captured to test the system. The results of this pre-pilot study are expected in July 2014. Then AIMHIGH plans to test a new UK initiative for improving the quality of care of AF patients which has incorporated ESC guidelines, and is expected to be ready for use in May 2014. If these two pre-pilot experiences prove viable we hope to be able to rollout the AIMHIGH initiative across Europe in the second part of 2015.”