Race, hypertensive disorders of pregnancy and outcomes in peripartum cardiomyopathy

Abstract

Background: Black women with peripartum cardiomyopathy (PPCM) have a higher prevalence of hypertensive disorders of pregnancy (HDP) and worse clinical outcomes compared with non-Black women. We examined the impact of HDP on myocardial recovery in Black women with PPCM.

Methods: A total of 100 women were enrolled into the Investigation in Pregnancy Associated Cardiomyopathy (IPAC) study. Left ventricular ejection fraction (LVEF) was assessed by echocardiography at entry, 6, and 12-months post-partum (PP). Women were followed for 12 months postpartum and outcomes including persistent cardiomyopathy (LVEF ≤35%), left ventricular assist device, (LVAD), cardiac transplantation, or death were examined in subsets based on race and the presence of HDP.

Results: Black women with HDP were more likely to present earlier compared to Black women without HDP (days PP HDP: 34 ± 21 vs 54 ± 27 days, P = .03). There was no difference in LVEF at study entry for Black women based on HDP, but better recovery with HDP at 6 (HDP: 52 ± 11% vs no HDP: 40 ± 14%, P = .03) and 12-months (HDP:53 ± 10% vs no HDP:40 ± 16%, P = .02). At 12-months, Black women overall had a lower LVEF than non-Black women (P < .001), driven by less recovery in Black women without HDP compared to non-Black women (P < .001). In contrast, Black women with HDP had a similar LVEF at 12 months compared to non-Black women (P = .56).

Conclusions: In women with PPCM, poorer outcomes evident in Black women were driven by women without a history of HDP. In Black women, a history of HDP was associated with earlier presentation and recovery which was comparable to non-Black women.

Figure 1:

Days PP at study entry by race and HDP -- Boxplots represent the interquartile range from the first to the third quartile. Median represented by a thick Black line across the interquartile range, and error bars represent 1.5 times the interquartile range. Days PP are shown between Black and non-Black women and by subgroups based on a history of HDP during index pregnancy. Significant differences between pairs of subgroups are shown using vertical hash (|) to represent comparison group, connected by a horizontal bar. HDP = hypertensive disorder of pregnancy; PP = post-partum. Among Black women, women with no history of HDP presented later than women with a history of HDP (P=0.03). Among women with no history of HDP, Black women presented significantly later than non-Black women (P<0.001).

Figure 2:

LVEF (%) by race and HDP at baseline, 6-, and 12-months PP -- Boxplots represent the interquartile range from the first to the third quartile. Median represented by a thick Black line across the interquartile range, and error bars represent 1.5 times the interquartile range. LVEF is shown between Black and non-Black women and by subgroups based on a history of HDP during index pregnancy. (A) Baseline. (B) Six-months (C) Twelve-months. Significant differences between pairs of subgroups are shown using vertical hash (|) to represent comparison group, connected by a horizontal bar. LVEF = left ventricular ejection fraction; HDP = hypertensive disorder of pregnancy; PP = post-partum. (A) At baseline, Black women with a history of HDP had a significantly lower mean LVEF than non-Black women with a history of HDP (P=0.001). (B) At 6 months PP, Black women with no history of HDP had a significantly lower mean LVEF than Black women with a history of HDP (P=0.03), non-Black women with a history of HDP (p=0.008) and non-Black women with no history of HDP (P<0.001). (C) At 12 months PP, Black women with no history of HDP had a significantly lower mean LVEF than Black women with a history of HDP (P=0.02), non-Black women with a history of HDP (p=0.001) and non-Black women with no history of HDP (P<0.001).

Figure 3:

Interaction of Self-designated Race (Black women versus non-Black women) with HDP for the determination of mean LVEF at 12 months PP. Y axis represents the LVEF (%) at 12 months PP. X axis compares non-Black versus Black women. Women with a history of HDP represented in red, those without a history of HDP in blue. Small circles represent the mean LVEF at 12 months PP for the 4 subgroups, with the thin vertical lines and error bars representing 95% confidence intervals. Solid thick lines connect means for non-Black and Black women for HDP groups (red) and non-HDP (blue). The non-parallel nature of the lines connecting the means represents graphically the significant interaction between Race and history of HDP for the determination of 12 month LVEF (p=0.002).

Figure 4:

LVEDD (A) and LAD (B) (mm) by race and HDP at baseline -- Boxplots represent the interquartile range from the first to the third quartile. Median represented by a thick Black line across the interquartile range, and error bars represent 1.5 times the interquartile range. LVEDD and LAD are shown between Black and non-Black women and by subgroups based on a history of HDP during index pregnancy. Significant differences between pairs of subgroups are shown using vertical hash (|) to represent comparison group, connected by a horizontal bar. LVEDD = left ventricular end-diastolic diameter; LAD = left atrial diameter; HDP = hypertensive disorder of pregnancy. (A) At baseline, Black women with no history of HDP had a significantly greater LVEDD than non-Black women with n history of HDP (P=0.005). (B) At baseline, Black women with no history of HDP had a significantly greater LAD than non-Black women with no history of HDP (P=0.04).