Author + information
- Tobias Koenig, MD,
- Denise Hilfiker-Kleiner, PhD and
- Johann Bauersachs, MD∗ ()
- ↵∗Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany
We read with interest the paper by Koczo et al. (1). Breastfeeding in patients with peripartum cardiomyopathy (PPCM) remains highly controversial. Because positive effects for the health of both mothers and infants have been reported, exclusive breastfeeding is recommended in healthy women up to 6 months. In contrast, convincing data are scarce regarding infant safety and breastfeeding women who take medications, and evidence to support breastfeeding by critically ill women is lacking (2). Potential long-term sequelae induced by drugs may be underestimated for the mother and the infant.
In this context, some aspects of the paper by Koczo et al. (1) must be scrutinized.
First, only 15% of all women enrolled in the Investigations of Pregnancy-Associated Cardiomyopathy (IPAC) registry were breastfeeding at the time of entry. This number is substantially lower than the U.S. national rate (83.2%) reported by the Centers for Disease Control and Prevention (3). In addition, the total duration of breastfeeding in the IPAC registry is unknown, thus precluding any firm conclusions.
Second, patients with severe heart failure were substantially underrepresented in the breastfeeding group (1). Mean left ventricular ejection fraction (LVEF) was 39% at entry, and the vast majority of patients were in New York Heart Association functional class I and II (80%). Compared with other PPCM cohorts, the breastfeeding group displayed only mild cardiac dysfunction.
Third, in their original IPAC report (4), the authors described significant numbers of heart transplantations, ventricular assist device implantations, and deaths. Moreover, there was a substantial difference in outcome depending on the LVEF at initial diagnosis (<30% vs. >30%). Event rates (ventricular assist device implantation or death) in the first year postpartum were significantly higher in patients with LVEF <30% at baseline. These important outcome data are not included in the current analysis (1).
In summary, it is not possible to make conclusions regarding outcome and prognosis of PPCM patients with moderate to severe heart failure based on this analysis (1). Given the concerns, we advocate against broadly recommending breastfeeding in patients with PPCM, particularly in women with severe heart failure. In line with this advice, the European Society of Cardiology advises against breastfeeding in women with severe heart failure (Class IIb recommendation) (5). If a shared decision is made to continue breastfeeding (e.g., in patients with mild to moderate heart failure), cautious use of heart failure drugs is recommended (6).
Please note: The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Basic to Translational Science author instructions page.
- 2019 The Authors
- Koczo A.,
- Marino A.,
- Jeyabalan A.,
- et al.
- Byrne J.J.,
- Spong C.Y.
- Centers for Disease Control and Prevention
- McNamara D.M.,
- Elkayam U.,
- Alharethi R.,
- et al.
- Bauersachs J.,
- König T.,
- van der Meer P.,
- et al.