Letter of response to: “Echocardiographic assessment and critical care management of peri-partum women with unexpected left ventricular failure”

Dear Editor

I read with interest the article by Dr Greatorex and colleagues in the May 2022 edition of JICS. ¹ I was pleased to see a detailed discussion about acute heart failure in pregnancy and the postpartum period, as this is an important cause of maternal mortality and morbidity.

However, I was surprised by some of the assertions and recommendations in the article. The authors suggest that peripartum cardiomyopathy is an autoimmune condition. This is a bold assumption given that the exact pathogenic mechanism of this condition remains unclear (and may well be heterogenous). Various genetic, endocrine (prolactin), haemodynamic, angiogenic and inflammatory factors have been suggested. Some small studies have identified autoantibodies but the clinical significance is unclear and there is little convincing evidence of an autoimmune aetiology.

Even more surprisingly, the authors state that steroid therapy should be considered at an early stage. Steroids are not mentioned in either European Society of Cardiology ² or American College of Cardiology guidelines. ³ This is because there is little to no evidence to support their use; the authors cite an uncontrolled case series of just four patients to support their statement.

There are other unusual statements in the article, including recommendations to test the pituitary-adrenal axis as part of the work-up of stress cardiomyopathy (this would be very difficult to interpret during critical illness), and to set a target haemoglobin of 10 g/dL (this is not supported by evidence and may even be harmful in certain conditions).

I do not doubt that expert opinion is often valuable to guide the management of individual patients, especially when there are gaps in the evidence. However, such statements of opinion should openly acknowledge the uncertainty, particularly when they are published in a high-profile journal.