Long-Term Outcomes of Peripartum Cardiomyopathy

By Michael H. Crawford, MD

Synopsis: A large, prospective, observational study from Israel of peripartum cardiomyopathy has shown that, in general, outcomes are favorable, with high rates of left ventricular function recovery that remain stable and with no mortality but also that show high rates of cardiovascular comorbidities during long-term follow-up.

Source: Tuvali O, Kuperstein R, Zwas DR, et al. Long-term outcomes in women with a history of peripartum cardiomyopathy. JACC Heart Fail. 2025; Oct 9. doi: 10.1016/j.jchf.2025.102702. [Online ahead of print].

Little is known about the long-term outcomes of peripartum cardiomyopathy (PPCM) patients. Thus, this large, prospective, observational study from three obstetric specialty clinics in Israel is of interest.

PPCM was diagnosed in 119 patients between 2002 and 2024. The time of diagnosis had to be in the last trimester or ≤ 6 months postpartum. The patients had to have symptoms and signs of heart failure without other known causes. Left ventricular ejection fraction (EF) had to be ≤ 45% by echocardiography, and the patients had to have at least three years of follow-up. A recovered EF was defined as ≥ 50%.

After applying these criteria, there were 96 patients in the main analysis with a mean age of 32 years and a median follow-up of nine years. About half of the patients were of African descent, about a quarter were of European descent, and the rest had indeterminant ancestry. Pregnancy-associated hypertension was present in 35%, but few had diabetes (< 10%). Mean EF was 38%, and 82% of the patients were New York Heart Association class III-IV.

Major complications, including thromboembolic events, cardiac arrest, ventricular tachycardia, circulatory support, massive pulmonary edema, and death, occurred in 40% of the patients within 30 days of the diagnosis. Genetic testing was done in 49 patients and seven had pathologic or likely pathologic results. EF recovered in 70% of the patients within six months and in 76% of the patients at one year. Most of the patients were taking one or more of the four standard heart failure medications or a diuretic. None were taking sodium-glucose cotransporter 2 (SGLT2) inhibitors or glucagon-like peptide-1 (GLP-1) receptor agonists.

During the long-term follow-up, only five patients had further declines in EF and five patients with persistent low EF eventually recovered their EF. Overall, there were no statistically significant changes in EF after six months. There were three deaths, and none were caused by cardiovascular (CV) events, even though CV disease was not uncommon during the long-term follow-up. Hypertension was diagnosed in 16% of patients, dyslipidemia in 12%, and diabetes in 9%. Moderate to severe valve disease occurred in six patients, five of whom had persistently low EF and developed significant mitral regurgitation. Various cardiac interventions were performed in 11% of patients. One patient underwent heart transplantation. Of the 96 patients, 56 had subsequent pregnancies (24 patients had one pregnancy and 27 had many). Of these patients, 88% had recovered EF and, overall, no significant changes in EF were observed.

The authors concluded that women with PPCM have a favorable prognosis with a high probability of recovered EF and very low mortality. Also, subsequent pregnancies had no significant effect on their clinical course.

Commentary

To the authors’ knowledge, this is the largest prospective observational study of PPCM to date. Prior smaller studies have shown lower recovery rates in African American patients (45%), indigent patients (35%), and patients from the Middle East (33%). However, in other groups, similar or higher recovery rates have been documented: United States overall (72%), Europe (66%), and Asian-Pacific (78%). One-year mortality also has been higher in other areas: 4% in the United States and Europe, compared to zero in this Israeli study. The authors speculated that these differences may be the result of their geographically concentrated diverse patient population, universal healthcare, and specialty obstetric clinics.

The Israeli study and others have noted high rates of CV morbidity during follow-up. Some of this may be the result of pregnancy-associated hypertension, which occurred in more than one-third of the patients and may drive long-term CV morbidity. Because of this observation, the authors recommend long-term continued CV disease surveillance in PPCM patients.

There are limitations to this study. All the patients came from three obstetrical specialty clinics, so the results in less specialized situations may be different. Of the 119 patients originally identified, some were lost to follow-up, but national health records showed that they were all alive at the time of this analysis. Very few patients had genetic testing, but of those, only 14% had a known pathologic or likely pathologic mutation. In addition, biomarkers were not assessed. Finally, none of the patients were taking the more recently developed drugs for heart failure, such as the SGLT2 inhibitors and GLP-1 receptor agonists.

Michael H. Crawford, MD, is Professor Emeritus of Medicine and Consulting Cardiologist, UCSF Health, San Francisco.