Predicting peripartum cardiomyopathy: a comprehensive updated meta-analysis

Background

Peripartum cardiomyopathy (PPCM) is a life-threatening form of heart failure presenting in late pregnancy or within six months postpartum. Traditionally considered rare and unpredictable, recent large-scale studies suggest a higher incidence than previously recognised and have identified potential risk factors (1).

Purpose

To systematically evaluate and quantify predictors of PPCM to support improved risk stratification and targeted clinical surveillance.

Methods

A systematic review and meta-analysis of human cohort and case–control studies published in English was performed. Studies including >5 PPCM cases were eligible. Meta-analyses were conducted when ≥4 studies reported on a specific predictor. Odds ratios (ORs) were calculated using random-effects models with inverse variance weighting. Heterogeneity was assessed using I² statistics. Subgroup analyses were performed according to study design (prospective vs retrospective) and national income level. The review is registered with PROSPERO. Fourteen predictors were analysed: advanced maternal age, African-Caribbean ethnicity, chronic kidney disease (CKD), diabetes mellitus, anaemia, low socioeconomic status, multiparity, primiparity, multifetal pregnancy, pre-eclampsia, obesity, hypertension, thyroid disorders, and nicotine smoking.

Results

Significant associations with PPCM were identified for most predictors. The highest odds were observed for CKD (OR 22.56), pre-eclampsia (OR 12.4), and hypertensive disorders (OR 7.9). Multifetal pregnancy, diabetes, anaemia, African-Caribbean ethnicity, and obesity were associated with a two- to four-fold increased risk. Advanced maternal age, low socioeconomic status, and nicotine smoking demonstrated smaller but significant risk increases (OR 1.5–1.7). Multiparity, primiparity, and thyroid disorders were not significantly associated with PPCM.

Moderate-to-high heterogeneity was observed across most analyses, except for smoking (I²=0%). There are many reasons for high heterogeneity; as mentioned by multiple studies the diagnosis of PPCM can often include other aetiologies such as Takotsubos cardiomyopathy, PPCM associated with hypertensive disorders which some researchers considered a different syndrome than non-hypertensive PPCM with different outcomes and predictors (3). Subgroup analyses demonstrated reduced heterogeneity when stratified by study design and national income level, with higher effect estimates observed in low- and middle-income countries.

Conclusion

Multiple clinical and demographic factors are significantly associated with PPCM, particularly CKD, pre-eclampsia, and hypertensive disorders. Risk magnitude appears greater in lower-resource settings however significant risk is still seen in high resource settings. These findings support enhanced surveillance and targeted risk assessment in high-risk populations to facilitate earlier diagnosis and improved outcomes.Meta-analysis results