Efficacy of guideline-based management and recurrence risk in peripartum cardiomyopathy: a multicenter cohort analysis

Abstract Background Peripartum cardiomyopathy (PPCM) is a rare, life-threatening condition marked by left ventricular systolic dysfunction (LVEF 45%) occurring in late pregnancy or the postpartum period. Despite advances in management, predictors of recovery and recurrence remain poorly characterized. Purpose This multicenter study assessed clinical outcomes, recovery of LVEF, changes in NT-proBNP and NYHA heart failure functional class, and factors linked to non-recovery in patients with PPCM treated according to contemporary heart failure guidelines. Methods This observational cohort study (2015–2023) included 98 patients from 4 centres with confirmed PPCM. All patients had a pre-pregnancy or first-trimester LVEF greater than 50%, and a PPCM diagnosis was established based on the presence of NYHA class II-III symptoms, echocardiographic evidence of LVEF 45%, and elevated NT-proBNP levels (≥300 pg/mL). The treatment protocol during pregnancy included beta-blockers administered to 100% of patients, diuretics used in 61%, and spironolactone in 50%. After delivery, therapy was expanded to include ACE inhibitors/ARNI in 69% of patients, SGLT2 inhibitors in 10% and digoxin in 10%. Results All patients were followed up for 6 months. At baseline, the mean LVEF was 37.5 ± 3.2%. Patients were retrospectively categorized into two groups: a recovered group (Group 1, n = 40, 41%), which included patients with LVEF either increased by 10% or/and reached 50%, and a non-recovered group (Group 2, n = 58, 59%) with patients with sustained or declined LVEF or improved less than 10% compared to baseline by the end of the follow-up period. At the baseline, NT-proBNP levels were 650 ± 150 pg/mL across all groups. After 6 months Group 1 had a significant drop in NT-proBNP to 250 ± 50 pg/mL (p 0.05 compared to baseline). In contrast, Group 2 showed persistently elevated NT-proBNP levels (850±65 pg/mL; p 0.05 for between-group comparison). Non-recovered patients were independently associated with age greater than 40 years (OR = 3.1, p=0.02), multiparity (3 or more births, OR = 2.8, p=0.04), and obesity (BMI ≥30 kg/m², OR = 2.5, p=0.03). Among the 5 patients who experienced subsequent pregnancies, recurrent PPCM was observed in 60% (3 out of 5 patients). Furthermore, 65% (64 out of 98) of the cohort continued to exhibit NYHA class II-III symptoms, including 20% (13 out of 64) achieving recovery of LVEF ≥50%. No mortality cases were observed throughout the study. Conclusion Guideline-directed therapy was associated with significant LVEF recovery in approximately 41% of patients and a 100% survival rate. However, advanced maternal age, multiparity, and obesity were independently predictive of non-recovery, and the recurrence rate in subsequent pregnancies was notably high. Future studies are needed for long-term multidisciplinary follow-up in this high-risk population.