Title:
Racial Disparities in Peripartum Cardiomyopathy: Eighteen Years of Observations

Authors:
Emily Kennedy, BS^1,2; Zachary Walker, MD^1,2, Indranee N. Rajapreyar, MD³, Jeff M. Szychowski, PhD^1,2,4; Marc G. Cribbs, MD³; Tera F. Howard, MD^1,2; Luisa A. Wetta, MD^1,2; Akila Subramaniam, MD^1,2; Alan T. Tita, MD^1,2; Rachel G. Sinkey, MD^1,2

Institutions:

1. Center for Women’s Reproductive Health, University of Alabama at Birmingham, Birmingham, Alabama
2. Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama
3. Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama
4. Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama

Background:

• Black women have greater than a three-fold risk of maternal mortality than White women
• Cardiomyopathy is a leading cause of maternal mortality.

Objective:

• To examine racial disparities in health outcomes among women with peripartum cardiomyopathy.

Study Design:

• Retrospective cohort of women with peripartum cardiomyopathy (PPCM)
• Inclusion criteria:

• • Women with NHLBI-classified PPCM
  • Care at UAB from January 2000–November 2017

• Black and White women were compared; race was self-reported.
• Women were excluded if left ventricular ejection fraction (EF) at diagnosis was unavailable.
• Primary outcome:

• • EF at diagnosis.

• Secondary outcomes:

• • cardiovascular outcomes
  • Markers of maternal morbidity
  • Resource utilization
  • Subsequent pregnancy outcomes

• Characteristics between groups were compared using Chi-square, Fisher’s exact, two sample Student t-test, and Wilcoxon rank-sum tests as appropriate.

Results:

• Ninety-five women met inclusion criteria: 46 (48%) Black and 49 (52%) White.
• Black women were more likely to be single, have public insurance, and deliver earlier (weeks): 36.5 ± 3.8 vs. 38.5 ± 2.0, p = 0.02.
• Nine (20%) Black vs 4 (8.5%) White women delivered at our center (p=0.11)
• Almost all diagnoses were postpartum (vs antepartum): 95.4% of Black and 93% of White women, p=0.11
• EF at diagnosis was not different between Black and White women (26.8% ± 12.5 vs. 28.7% ± 9.9, p=0.41)
• Though non-significant, fewer Black women had myocardial recovery to EF ≥ 55%: 35% vs 53%, p = 0.07.
• More Black women underwent ICD placement (33% vs 14%, p=0.03).
• Deaths were not significantly different: 5 (11%) Black women vs 3 (6%) White women (p=0.48).
• Black women had higher rates of resource utilization (Table 1).
• In the subsequent pregnancy, Black women had a lower initial EF and were less likely to recover postpartum (Table 2).

Conclusion:

• Black and White women have similar mean EF at diagnosis of PPCM but black women have more severe left ventricular systolic dysfunction leading to worse outcomes, increased resource use, and lower EF entering the subsequent pregnancy.

Table 1: Outcomes of Women with Peripartum Cardiomyopathy from 2000 – 2017

EF= Left Ventricular Ejection Fraction, ECMO= Extracorporeal Membrane Oxygenation, LVAD= Left Ventricular Assist Device, ICD= Implantable cardioverter-defibrillator, ER= Emergency Room, ICU= Intensive Care Unit

Data are presented as n (%), mean + standard deviation, or median (range)

⁺Median (Q1-Q3)

*Median (5^th-95^th percentile)

Table 2: Subsequent Pregnancy Outcomes after a Peripartum Cardiomyopathy Diagnosis

EF = Left Ventricular Ejection Fraction, GA= Gestation age

Data are presented as mean (range) or mean + standard deviation