Delayed recognition of peripartum cardiomyopathy presenting with severe heart failure: a case report

Background: Peripartum cardiomyopathy (PPCM) is a rare but potentially fatal cause of heart failure that occurs towards the end of pregnancy or within the first 5 months postpartum, in the absence of other identifiable cause of cardiac dysfunction. It is characterized by left ventricular systolic impairment, with an ejection fraction (LVEF) typically ≤ 45%. While most cases are diagnosed shortly after delivery, delayed presentations can occur, leading to significant diagnostic challenges and complicate treatment. Case summary: We report a case of a 40-year-old multiparous (Para 3) woman, who developed progressive dyspnoea beginning 2 months after delivery. Despite two earlier medical care visits, her symptoms were initially misdiagnosed. She represented with overt symptoms of heart failure 1 month later. Investigations encompassing transthoracic echocardiography, cardiac magnetic resonance imaging, coronary angiography, and NT-proBNP confirmed PPCM with a severely reduced LVEF of 16%. She was promptly initiated on guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF), including an angiotensin receptor-neprilysin inhibitor and a sodium-glucose cotransporter-2 inhibitor. At 3-month follow-up, her symptoms had resolved, and LVEF recovered to 56%. Discussion: This case highlights the diagnostic challenge of delayed-onset PPCM and reinforces the importance of maintaining high suspicion in postpartum women presenting with persistent dyspnoea. Early initiation of GDMT for HFrEF can lead to full functional recovery. Routine postpartum surveillance should include careful assessment for cardiopulmonary symptoms, even in the absence of overt risk factors, to prevent delays in diagnosis and management.