Case Report Poster Session

ABSTRACT

ESC GUIDELINES REAL-WORLD

IMPLEMENTATION IN INDONESIAN TYPE
D STATE HOSPITAL: MANAGING ACUTE
HEART FAILURE IN PATIENTS WITH
PERIPARTUM CARDIOMYOPATHY
Jeffri Gunawan1, Nopriza Eprianti1, Jessica Theo2, Dono Antono3,
Lukman Hakim Makmun3
1
Department of Internal Medicine, Tais Prefecture General State Hospital, Indonesia
2
Wakatobi Prefecture General State Hospital, Indonesia
3
Division of Cardiology, Department of Internal Medicine, Faculty of Medicine,
Universitas Indonesia, Cipto Mangunkusumo National State Hospital, Indonesia

INTRODUCTION
Patients with peripartum cardiomyopathy are not uncommon in developing countries
especially those with high salt intake. Management of PPCM may be challenging in a
way to implement guidelines in health care center with limited resources.

CASE ILLUSTRATION
A 41-year-old woman admitted worsening dyspnea on exertion since 5 days before
admission. She delivered her third child 7 months ago by spontaneous labor and started
to suffer from dyspnea 3 months after labor. Jugular venous distention and peripheral
edema were found with cardiomegaly on x-ray. Echo revealed global hypokinetic
ventricles with reduced ejection fraction.

DISCUSSION
Risk factors for PPCM in this patient are multiparity and hypertension. Studies stated
nutritional disorders like salt overload as causes, which in this case we strongly
suspected as dietary ingredient of local foods mostly contain high sodium
concentration.1 Anticoagulation is recommended in patients with intracardiac thrombus
detected by imaging or evidence of systemic embolism.
In accordance with the above guidelines, we did not give any oxygenation on
admission due to SpO2 > 95%. Due to its congestive nature, we immediately gave her
diuretics with significant improvement afterwards. After stabilized, we manage the
therapy of the heart failure in accordance with the guidelines by giving RAAS inhibitor,
beta-blocker, and anticoagulants for intraventricular thrombus.

CONCLUSION
In hospital with limited resources, a detailed history taking regarding the natural history
of disease and careful physical examination may take pivotal role. Management of acute
heart failure in type D hospital according to current guidelines is possible without
significantly modify the algorithm.
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MANUSCRIPT
INTRODUCTION
The Working Group on Peripartum Cardiomyopathy (PPCM) of the European Society of
Cardiology has a terminology of PPCM as an idiopathic cardiomyopathy presenting with
heart failure (HF) secondary to left ventricular systolic dysfunction towards the end of
pregnancy or in the months following delivery, where no other causes of HF discovered.2,3
Symptoms and signs are often typical for heart failure but, due to the special
physiological situation of pregnancy and post-partum, a broad spectrum of symptoms is
reported in PPCM patients. Management of PPCM may be challenging especially to
implement guidelines in health care center with limited resources.

CASE ILLUSTRATION
A 41-year-old woman admitted worsening dyspnea since 5 days before admission. The
dyspnea got worsened in daily activity such as bathing or walking up the stairs, accompanied
with paroxysmal nocturnal dyspnea (PND) and orthopnea as well.

Figure 1. Clinical portrait of a 41-year-old female with congestive heart failure due to PPCM

She suffered from sleep deprivation due to her PND. She also admitted weakness,
dizziness, frequent palpitations, and tight chest pain which was referred to the back and left
wrist.
She delivered her third child 7 months ago by spontaneous labor and started to suffer
from dyspnea 3 months afterwards. Antenatal care had not been carried out for this
pregnancy. On physical exam we found signs of congestion as jugular venous distention and
pitting edema.
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Figure 2. Chest X-ray shows cardiomegaly with CTR 64%, grounded apex, normal aortic
knob.

Figure 3. ECG revealed regular rhythm with ventricular extrasystoles which improved on the
second day of hospitalization.
On echocardiography by eyeballing technique global hypokinetic ventricles were
discovered with decrease in systolic and diastolic function with EF roughly below 45%,
dilatations of atria and ventricles, and intraventricular mass sized 2.62 cm x 1.40 cm.
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Figure 4. Echocardiography shows dilated both right and left atria.

thrombus

Figure 5. Echocardiography finding of intraventricular thrombus in the left ventricle

She was later diagnosed with acute heart failure due to peripartum cardiomyopathy
(AHF on PPCM) and treated accordingly.
ARB was prescribed since she was already in postpartum period, beta blocker also
diuretics with caution, and anticoagulants due to its newly-diagnosed intraventricular
thrombus on echo.
On the second day the patient has already improved both in clinical symptoms and
ECG appearance.
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DISCUSSION
Risk factors for PPCM in this patient are multiparity and hypertension. Studies stated
nutritional disorders like salt overload as causes, which in this case we strongly suspected as
the dietary ingredient of local foods mostly contain high sodium concentration.1
Management goals for PPCM are similar with heart failure due to other causes.
Anticoagulation is recommended in patients with intracardiac thrombus detected by
imaging or evidence of systemic embolism. In this patient we encounter an intraventricular
thrombus in the left ventricle hence we gave anticoagulants along the hospitalization.

Figure 6. Systematic management of heart failure in peripartum cardiomyopathy4

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In accordance to above guidelines, we did not give any oxygenation on admission due
to SpO2 > 95%. Due to its congestive nature, we immediately gave diuretics. After stabilized,
we manage the therapy of the heart failure by giving angiotensin receptor blocker, beta-
blocker, and anticoagulants for intraventricular thrombus.
Our management is similarly specific to ESC guidelines for postpartum stabilized
heart failure on PPCM. ARB is used as first line due to results of recent studies reflected in
Forest plot below.

ARB seems to have a statistically significant superior results in terms of all-cause

mortality and hospitalization. While risk ratio of trials favoring ACEI showed insignificant
statistical results due to their 95% confidence intervals which crossing the borderline.5
Differences still remain on ivabradine and bromocriptine use and also wearable
cardiac defibrillator (WCD) therapy considerations, as all is not available in our hospital nor
in the nearest regional referral hospital. We postpone the MR antagonist administration as we
reserve this agent for the next line therapy if the first-line drugs show no improvement.
On the second day of hospitalization the patient showed marked improvement. We
hope this patient, although with some limitations in our care, will soon get a reversible left
ventricular function improvement since Falk and Hershberger stated the LV ejection fraction
may improve to normal state in 50% of patients receiving standard medical therapy although
they are still at risk for recurrent PPCM in the future.6
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CONCLUSION
Echocardiography is a modality of choice for PPCM, although it may not be available in all
type D hospitals.
In hospital with limited resources, a detailed history taking regarding the natural history of
disease and careful physical examination may take pivotal role.
Management of acute heart failure in type D hospital according to current guidelines is
possible without significantly modify the algorithm.

REFERENCES
1. Carson P. Peripartum Cardiomyopathy. In. emedicine: medscape; 2016.
2. Regitz-Zagrosek V, Lundqvist CB, Borghi C, et al. ESC Guidelines on the management of
cardiovascular diseases during pregnancy. European Heart Journal 2011;32:3147-97.
3. Bauersachs J, Arrigo M, Hilfiker-Kleiner D, et al. Current management of patients with severe
acute peripartum cardiomyopathy: practical guidance from the Heart Failure Association of the
European Society of Cardiology Study Group on peripartum cardiomyopathy. European Heart
Journal 2016;18:1096-105.
4. Committee for Practice Guidelines European Society of Cardiology. 2018 ESC Pocket
Guidelines: CVD during Pregnancy. 2018.
5. Pepine C. Angiotensin type 1 receptor blockade versus ACE inhibition in the treatment of
heart failure: Reesults of 3 clinical trials. Vascular Biology Working Group:113.
6. Falk R, Hershberger RE. The dilated, restrictive, and infiltrative cardiomyopathies. In: Mann
D, Zipes DP, Libby P, Bonow RO, Braunwald E, ed. Braunwald's Heart Disease A Textbook of
Cardiovascular Medicine. 10th ed. Philadelphia: Elsevier; 2015:1561-2.