Special Populations and Patients With Concomitant Disorders

Ethnic and Genetic Considerations

HF is more prevalent and associated with a worse prognosis in African Americans compared to the general population.1 Unfortunately, deficiencies in disease prevention, detection, and access to treatment are well documented in minority populations. African Americans and other races are under-represented in clinical trials, compromising the extrapolation of results from these studies to ethnic subpopulations. The influence of race on efficacy and safety of medications used in HF treatment has received additional attention with the advent of pharmacogenomics (the influence of genetics on drug response). The application of race and genetics to pharmacotherapeutic decision making for HF is in the early stages. However, these concepts are being applied to the use of hydralazine and isosorbide dinitrate in African American patients. 8 It is anticipated that further investigation will lead to better insight relating to the clinical applicability of genetic variations to drug responses.

Peripartum Cardiomyopathy and Pregnancy

Peripartum cardiomyopathy (PPCM) is currently defined as clinical and echocardio-graphic evidence for new-onset HF occurring during pregnancy and up to 6 months after delivery, with other etiologies excluded. Although PPCM is not well understood, it manifests in pregnant women of all ages, but the risk is elevated in women older than 30 years of age.45 The true incidence of idiopathic PPCM is debatable, with reported rates for peripartum HF at 1 case per 100 to 4,000 deliveries.46 The leading hypothesis for PPCM pathogenesis is myocarditis caused by a viral infection or an abnormal immune response to pregnancy. HF may persist after delivery but can be reversible (with partial or full recovery of cardiac function) in many cases.45

The clinical presentation of peripartum HF is indistinguishable from that of other types of HF. Initial treatment is also similar, with the exception of ACE inhibitors and ARBs being contraindicated during the antepartum period. Treatment includes reducing preload by sodium restriction and diuretics, afterload reduction with vasodilators, and sometimes inotropic support with digoxin. Hydralazine is utilized frequently in pregnancy and is classified as FDA pregnancy category C. Labetalol is used for acute parenteral control of BP, but long-term P-blocker use corresponds with low birth-weight infants. Management of the cardiomyopathy after delivery includes use of ACE inhibitors and P-blockers, although these treatment guidelines have been extrapolated from studies in patients with idiopathic dilated cardiomyopathy rather than specific trials in PPCM. Patients with PPCM also have a high rate of thromboembolism. Treatment options during pregnancy are limited to unfractionated heparin and low-molecular-weight heparin as warfarin is contraindicated. After delivery, anticoagulation is recommended in patients with LVEF less than 20%.46

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