Peripartum cardiomyopathy: diagnosis, bromocriptine, recovery and the next pregnancy

• This page covers how peripartum cardiomyopathy (PPCM) is defined, why it happens, how it presents and is diagnosed, acute treatment, drugs before and after delivery, bromocriptine, anticoagulation, sudden death prevention, recovery and the next pregnancy.^[1]

• General heart failure treatment is covered in Heart failure with reduced ejection fraction, and ICD and CRT rules in ICD and CRT indications in heart failure.

• Myocarditis is covered in Myocarditis: presentation, biopsy criteria, management; shock and mechanical support in Cardiogenic shock: staging, MCS selection and outcomes; other heart disease in pregnancy in Cardiovascular disease in pregnancy.

Definition and epidemiology

ESC 2025 defines PPCM as HF with reduced LVEF <45%, without any other cause of HF.^[1] It occurs mainly during the peripartum period or in the months following delivery, termination or miscarriage.^[1] ESC 2025 calls it a potentially life-threatening condition and essentially a diagnosis of exclusion that requires urgent management.^[1]

• AHA/ACC/HFSA 2022 defines PPCM as systolic dysfunction, typically LVEF <45%, often with LV dilation, occurring in late pregnancy or early postpartum with no other identifiable cardiomyopathy cause.^[4]

ESC 2025 says PPCM complicates 1 in 2000 births worldwide.^[1]

• It adds that incidence varies with geographical region, ethnicity and socioeconomic factors: 1–4 per 1000 births in the United States of America and 10 per 1000 births in north-western Nigeria.^[1]

Data from 49 countries showed that most women presented with PPCM in the post-partum stage (ESC 2025).^[1]

• AHA/ACC/HFSA 2022 gives the highest incidences in Nigeria, Haiti and South Africa, and a US incidence of 1 in 1000 to 8000 deliveries that has risen over time.^[4]

It lists maternal age >30 years, African ancestry, multiparity, multigestation, preeclampsia/eclampsia, anaemia, diabetes, obesity and prolonged tocolysis as risk factors.^[4]

^{[4] [1]}

Mechanisms and genetics

ESC 2025 says recent trials suggest a "multiple hit" theory, with an accumulation of genetic and environmental risk factors.^[1] It describes growing evidence that several mechanisms converge on a common pathway involving inflammation, unbalanced oxidative stress and the anti-angiogenic 16 kDa prolactin.^[1] The 16 kDa prolactin induces endothelial dysfunction and damage, which subsequently leads to HF.^[1] Blocking prolactin with the dopamine D2 receptor agonist bromocriptine has emerged as a potential disease-specific therapy (ESC 2025).^[1] A systemic or local increase in other anti-angiogenic factors, such as soluble fms-like tyrosine kinase-1 (sFlt-1), contributes to local and widespread vascular dysfunction.^[1]

• ESC 2025 reports variants in TTN, FLNC, BAG3 and DSP in up to 15% of women with PPCM, TTN truncating variants being the most common.^[1]

The prevalence of these four genes in PPCM was comparable to that in DCM cohorts, supporting the similarity between the two (ESC 2025).^[1] ESC 2023 cardiomyopathies says TTN truncating variants are the most commonly involved, found in about 10% of patients.^[2] It adds that approaches to genetic testing in PPCM have been suggested to mirror those taken in DCM.^[2] ESC 2023 lists peripartum among the non-genetic causes of DCM in its Table 20.^[2] It reports causative gene variants in 10–15% of chemotherapy-induced, alcoholic or peripartum DCM.^[2]

^{[1] [2]}

AHA/ACC/HFSA 2022 recognises a genetic contribution, particularly titin gene mutations.^[4] ESC 2022 ventricular arrhythmias said a genetic contribution may be present in up to 20% of patients with PPCM, in particular titin-truncating variants.^[6]

Presentation and diagnosis

ESC 2025 says PPCM may present with subtle manifestations, but most women present with acute heart failure with severe symptoms (NYHA III/IV).^[1] Mild to moderate symptomatic cases are often mistaken for physiological changes of pregnancy, especially post-partum.^[1] In acute HF during pregnancy generally, ESC 2025 notes that symptoms and signs can be misinterpreted as changes due to pregnancy.^[1]

AHA/ACC/HFSA 2022 says most women present with HF within 1 month postpartum, and that cardiogenic shock, arrhythmias or venous-arterial thromboembolism are all possible.^[4] In the ESC EORP registry (739 women in 49 countries), symptom onset was most often within 1 month of delivery (44%).^[10] At diagnosis, 67% had severe (NYHA III/IV) symptoms and 67% had an LVEF ≤35%.^[10]

Diagnostic measures in a woman with suspected PPCM should include ECG, natriuretic peptides and echocardiography (ESC 2025).^[1] The management strategy should be discussed within the Pregnancy Heart Team, considering maternal and foetal outcomes.^[1]

^[1]

Myocarditis and other differentials

ESC 2025 says myocarditis is a differential diagnosis and should be excluded by CMR.^[1] ESC 2025 myocarditis guidance, in its section on pregnancy-associated myocarditis, says there is no clear distinction between its phenotype and that of PPCM.^[7] That section says women develop HF symptoms during late pregnancy or after delivery, most being diagnosed after delivery, typically in the first month post-partum.^[7] That section adds that PPCM is sometimes associated with myocardial inflammation, more common particularly in patients presenting with arrhythmias.^[7]

That section says that, as there are no specific studies of pregnancy-associated myocarditis, the guidance for PPCM should be followed.^[7] That section says transthoracic echocardiography should be performed in any suspected case, and that in PPCM LVEF is typically <45%.^[7] That section adds that the LV apex should be viewed carefully to detect intracardiac thrombi, and that BNP or NT-proBNP are usually markedly elevated.^[7] In that section, CMR is an advanced imaging modality if the echocardiogram is inadequate, but gadolinium-based contrast agents should be avoided during pregnancy.^[7] That section calls CMR crucial to differentiate underlying causes.^[7]

• When new-onset VT develops during the last 6 weeks of pregnancy or during the first month post-partum, ESC 2025 says underlying PPCM should be excluded.^[1]

ESC 2022 ventricular arrhythmias said the same for new-onset VT in the last 6 weeks of pregnancy or the early post-partum period.^[6]

• ESC 2025 reports that women with PPCM and pre-eclampsia had a higher risk of adverse neonatal outcome but a higher likelihood of LV recovery (LVEF ≥50%).^[1]

AHA/ACC/HFSA 2022 advises close obstetric monitoring for preeclampsia, which it says shares risk factors and pathogenesis with PPCM.^[4]

Acute heart failure and cardiogenic shock

ESC 2025 notes that acute HF can develop in women without pre-existing heart disease, as can be the case in PPCM.^[1] ESC 2025 says treatment of acute HF caused by PPCM follows the main principles of acute HF management during and after pregnancy.^[1]

• Pregnant women presenting with acute HF require urgent hospital admission and referral to an expert centre with advanced HF care, including on-site surgery and mechanical circulatory support or a transplant programme as backup.^[1]

^[1]

ESC 2025 says levosimendan is given as a continuous infusion without an initial loading dose; dobutamine is an option, whereas adrenaline should be avoided.^[1] In PPCM, it says mechanical circulatory support should be considered in women with persistent cardiogenic shock despite medical treatment.^[1] For pregnant women generally, it says mechanical support, preferably VA-ECMO, should be considered in severe refractory cardiogenic shock.^[1] Milder acute HF can be treated with oral diuretics, beta-1-selective beta-blockers (bisoprolol, metoprolol succinate), hydralazine and oral nitrates (ESC 2025).^[1]

ESC 2023 cardiomyopathies says temporary mechanical support has been used successfully in severe PPCM and should be considered with haemodynamic instability despite inotropic support.^[2] AHA/ACC/HFSA 2022 calls patient-centred multidisciplinary planning essential, including early mechanical support for shock.^[4]

^[1]

Heart failure drugs: pregnancy, delivery and breastfeeding

ESC 2025 says most HF medications are foetotoxic and therefore contraindicated during pregnancy, naming ACE-Is, ARBs, MRAs and SGLT2 inhibitors.^[1]

• In the post-partum period, full HF treatment can be initiated, except when lactation and breastfeeding are necessary for nutritional reasons; then ARBs and SGLT2 inhibitors should be avoided.^[1]
• In that post-partum setting, including breastfeeding, ESC 2025 considers spironolactone safe; its drug section says spironolactone is considered safe during lactation because of extensive metabolism to canrenone, whereas aldosterone antagonists, including spironolactone, are contraindicated in pregnancy.^[1]

^{[1] [3] [4]}

AHA/ACC/HFSA 2022 lists furosemide, beta-blockers (most commonly metoprolol), hydralazine and nitrates as HFrEF medications considered acceptable during pregnancy, within multidisciplinary shared decision-making.^[4]

• It says ACEi and ARB are strictly contraindicated, citing second- and third-trimester renal and tubular dysplasia, oligohydramnios, fetal growth restriction and intrauterine fetal death among the associated harms.^[4]

Breastfeeding and lactation

ESC 2025 says a secondary effect of bromocriptine is stopping lactation, which allows full HF treatment of a mother who is not breastfeeding.^[1] The downsides of stopping lactation include psychological implications for the mother and the loss of the infant’s source of nutrition.^[1] Elsewhere it notes that lactation can be inhibited with cabergoline in general, or bromocriptine in PPCM.^[1]

^[1]

AHA/ACC/HFSA 2022 says women with PPCM were historically counselled against breastfeeding, but breastfeeding may even be associated with LV recovery.^[4] Postpartum women who breastfeed can start an ACEi (enalapril or captopril preferred), and metoprolol remains the preferred beta-blocker.^[4] Its Table 30 says diuretics can suppress lactation, but with neonatal follow-up furosemide may be appropriate.^[4] In its section on pregnancy-associated myocarditis, ESC 2025 myocarditis guidance says most HF medications are compatible with breastfeeding after delivery.^[7]

ESC 2025 says women with PPCM are particularly vulnerable to depression.^[1]

Bromocriptine

^[1]

ESC 2025 says these downsides of stopping lactation indicate that women with moderate and severe HF in PPCM are the preferred candidates for bromocriptine.^[1]

• It reports a multicentre randomized study of two dosages in severe PPCM: 2.5 mg daily for 1 week versus 5 mg daily for 2 weeks then 2.5 mg daily for 6 weeks.^[1]
• ESC 2025 reports that study as observing a high LV recovery rate at 6 months, with no significant differences between 1 and 8 weeks, suggesting a 1-week addition would be beneficial.^[1]

Data in pregnant women with PPCM and cardiogenic shock are limited; personalized dosing to suppress prolactin may be a viable option in these cases.^[1]

• In ESC 2025 Figure 22, on acute HF and cardiogenic shock in pregnancy and up to 6 months post-partum, bromocriptine appears as "If delivered: Bromocriptine (Class IIb)", with a footnoted starting dose of 2.5 mg twice daily with up-titration if needed.^[1]

• AHA/ACC/HFSA 2022 says the efficacy and safety of bromocriptine for acute PPCM remain uncertain, and that randomized placebo-controlled trials are needed, particularly with contemporary GDMT and shock management.^[4]

• Its Table 30 footnote says bromocriptine may currently be most justified with LVEF <25% or cardiogenic shock, and that the downsides of prohibiting breastfeeding should be considered.^[4]

• In its section on pregnancy-associated myocarditis, ESC 2025 myocarditis guidance says bromocriptine has been shown to improve LVEF at 6 months, but the results are contradictory.^[7]

ESC 2023 cardiomyopathies says bromocriptine as disease-specific therapy added to standard HF therapy has shown promising results in two clinical trials.^[2] ESC 2026 heart failure lists randomized clinical trials for the treatment of PPCM among its gaps in evidence.^[3]

The studies behind the row

^{[4] [9] [4] [8] [12]}

In the 2010 pilot, mothers receiving bromocriptine could not breastfeed, so the 6-month outcome of their children was a secondary end point.^[9]

• AHA/ACC/HFSA 2022 also reports a Burkina Faso randomized trial in 96 women with acute PPCM, in which 4 weeks of bromocriptine was associated with LVEF recovery and lower mortality (16.6% versus 29.1%).^[4]

^{[4] [1] [8]}

Anticoagulation

^{[1] [4]}

AHA/ACC/HFSA 2022 reports intracardiac thrombi in about 16% to 17% of acute HF caused by PPCM, with 9% thromboembolic events in 2 separate cohorts.^[4] It says women with an intracardiac thrombus or a thromboembolic event receive anticoagulation as per standard of care.^[4] It adds that hypercoagulability is most pronounced in the first 6 to 8 weeks postpartum.^[4]

• If bromocriptine is used for postpartum women with severe acute HF caused by PPCM and LVEF <35%, it says at least prophylactic-dose anticoagulation should accompany it.^[4]

• In its section on pregnancy-associated myocarditis, ESC 2025 myocarditis guidance says LMWHs do not cross the placenta and are preferred in pregnancy if thromboembolic risk is high.^[7]

• That section says direct oral anticoagulants are less well studied in pregnancy and should be avoided, and that anticoagulation should continue until LV function recovers.^[7]

Arrhythmias and sudden death

ESC 2025 says PPCM may cause ventricular tachyarrhythmias, so patients should be monitored.^[1]

• As about 50% of women with PPCM recover within 1 year of delivery, it says a wearable cardioverter defibrillator may be considered for pregnant women with LVEF <35% at risk of sudden cardiac death, as bridging therapy to recovery.^[1]

^[1]

• ESC 2023 cardiomyopathies says thresholds for early ICD implantation in PPCM should be higher than in other conditions because of a high rate of spontaneous recovery after delivery.^[2]
• ESC 2023 cardiomyopathies had said that data on the benefit of the wearable defibrillator for primary prevention outside the early phase of myocardial infarction, for example in PPCM, are scarce and that no recommendation could be made; the ESC 2025 pregnancy row above is the newer ESC row.^[2][1]
• ESC 2022 ventricular arrhythmias said that in PPCM, thresholds for early ICD implantation are higher than in other conditions because of a high rate of spontaneous recovery after delivery, and that wearable defibrillators have been suggested to temporarily prevent sudden cardiac death during the first 3–6 months after diagnosis of PPCM with LVEF ≤35%, while awaiting recovery; its general wearable-defibrillator section said data on primary prevention in other clinical situations (e.g. acute myocarditis, a primary prevention indication during pregnancy) are sparse and no recommendations can currently be made.^[6]

Outcomes and recovery

• ESC 2025 lists LVEF <30%, LV end-diastolic diameter >60 mm, biventricular dysfunction, QT prolongation, delayed diagnosis, and Middle Eastern or African ethnicity and/or geography as key indicators of risk of complications.^[1]

Age (>40 or <20 years), antepartum diagnosis, haemodynamics at presentation and cardiac biomarkers can further refine risk (ESC 2025).^[1] AHA/ACC/HFSA 2022 relates prognosis to initial LVEF, LV thrombosis, RV involvement, preeclampsia, geographic region and race.^[4]

• ESC 2025 says myocardial recovery, defined as LVEF >50%, has been shown in 46% of women at 6 months, ranging from 25% to 62% by region.^[1]
• It reports EORP registry mortality of 2.4% at 1 month and 6% at 6 months, with HF and cardiac arrest the most frequent causes of death.^[1]

At 1 year, death from any cause occurred in 8%, with regional variation: Europe 5%, Africa 6%, Asia–Pacific 9% and Middle East 19%.^[1]

• LVAD or heart transplantation have been reported in up to 10% of PPCM cases, with inferior survival compared with other age-adjusted transplant recipients (ESC 2025).^[1]

^{[10] [11] [13]}

• In IPAC, an initial LVEF <0.30, LVEDD ≥6.0 cm, black race and presentation after 6 weeks post-partum were associated with a lower LVEF at 12 months.^[13]

• AHA/ACC/HFSA 2022 reports that ROPAC, which describes pregnancy outcomes for 1321 women with structural heart disease, found that women with prepregnancy or peripartum cardiomyopathy had the highest mortality rate (2.4%).^[4]

• AHA/ACC/HFSA 2022 says LV recovery and survival are generally favourable in developed countries, citing 93% transplant- or LVAD-free 1-year survival in a 100-patient US registry.^[4]

• In its section on pregnancy-associated myocarditis, ESC 2025 myocarditis guidance says PPCM has been associated with a higher recovery rate than other forms of HFrEF.^[7]

That section adds that remission frequently occurs within 3 to 6 months, and that delayed recovery can occur after 2 years.^[7]

• ESC 2025 reports foetal prematurity and low birth weight as common, and a 3.4 times higher incidence of cardiovascular disease and 5 times higher mortality in the children.^[1]

^{[1] [13]}

How long to treat after recovery

^{[1] [5]}

ESC 2025 says full HF treatment should be given during the first year after complete LV function recovery.^[1] Stepwise discontinuation may be considered after 1 year if complete recovery is achieved, assuming no genetic predisposition has been identified.^[1] It adds that recent data indicated a higher risk of LVEF relapse in subsequent pregnancies in women with PPCM who had discontinued HF medication.^[1] ESC 2023 cardiomyopathies says medication should be continued in the presence of persistent cardiac dysfunction.^[2]

• As practice advice, NHFA/CSANZ 2018 says cessation of neurohormonal antagonists can be considered with specialist advice and close monitoring in some circumstances, such as HF with recovered ejection fraction due to PPCM, where there are no other indications such as hypertension or vascular disease.^[5]
• If the dose is reduced or ceased, close follow-up (for example natriuretic peptides and serial imaging of LV size and function) should be undertaken or considered.^[5]

In its section on pregnancy-associated myocarditis, ESC 2025 myocarditis guidance says lifelong treatment has not been proven to be necessary.^[7] That section names treatment withdrawal and incomplete recovery of LV function as risk factors for recurrence.^[7]

Subsequent pregnancy and contraception

^{[1] [4] [3]}

• Among its key messages, ESC 2025 says that in women with PPCM and DCM, subsequent pregnancy is not recommended if LV function does not normalize.^[1]

• It says more than mild LV dysfunction before a new pregnancy increases the risk of LVEF deterioration, but women with recovered LV function also remained at risk of relapse.^[1]

• ESC 2025 reports that, in the most recent EORP paper following women with subsequent pregnancies after PPCM, maternal mortality was lower than in previous reports, at 2% at 198 days after delivery.^[1]

• With only mild LV dysfunction, stress echo without contraindicated HF medication may help stratify risk before a new pregnancy; good contractile reserve off HF medication may be an encouraging sign (ESC 2025).^[1]

• If a new pregnancy is planned, stopping beta-blockade may not be advisable, and restarting it may be beneficial in a subsequent pregnancy irrespective of baseline LV systolic function (ESC 2025).^[1]

AHA/ACC/HFSA 2022 says subsequent pregnancies after PPCM have been associated with further falls in LV function, maternal death and adverse fetal outcomes.^[4] It names LVEF <50% before a subsequent pregnancy as the strongest prognostic determinant.^[4]

• It reports an international systematic review: with persistent LV dysfunction (93 pregnancies), 48% had further LVEF deterioration, 49% HF symptoms and 16% died; with recovered function (98 pregnancies), the rates were 27%, 32% and 0%.^[4]

• For women planning pregnancy imminently, AHA/ACC/HFSA 2022 Table 30 describes stopping any ACEi, ARB, ARNi, MRA, SGLT2i or ivabradine; within shared decision-making, continuing a beta-blocker (most commonly metoprolol), hydralazine and nitrates; and adjusting diuretic dosing to minimise the risk of placental hypoperfusion.^[4]

It suggests repeat echocardiography, ideally about 3 months after these changes, to confirm stable myocardial structure and function before conception.^[4] NHFA/CSANZ 2018 says women with PPCM after a previous pregnancy have increased risks of recurrence, especially with persisting LV systolic dysfunction.^[5]

• In its section on pregnancy-associated myocarditis, ESC 2025 myocarditis guidance says pre-conception counselling should include discussion of the potential risks of recurrent myocardial dysfunction, even after recovery.^[7]

• Among its gaps in evidence, ESC 2025 says the potential for recovery in PPCM remains unclear and the risks in subsequent pregnancies are not well defined.^[1]

^[1]

Pitfalls

• Mistaking mild to moderate symptomatic PPCM for the physiological changes of pregnancy, especially post-partum (ESC 2025).^[1]
• Missing myocarditis: ESC 2025 says it is a differential diagnosis that should be excluded by CMR.^[1]
• Continuing ACE-Is, ARBs, ARNIs, MRAs, ivabradine or SGLT2 inhibitors in pregnancy: not recommended (ESC 2025, Class III, Level C).^[1]
• Giving bromocriptine without anticoagulation: adding at least prophylactic LMWH should be considered (ESC 2025, Class IIa, Level C).^[1]
• Implanting an early ICD: ESC 2023 says thresholds should be higher in PPCM than in other conditions because of a high rate of spontaneous recovery after delivery.^[2]
• Stopping HF treatment as soon as LVEF recovers: ESC 2025 says treatment in accordance with HF guidelines should be considered for at least 12 months after complete LV recovery when a reversible course is assumed (Class IIa, Level C).^[1]
• Reassuring a woman whose LV function has recovered that a further pregnancy carries no risk: ESC 2025 says recovered women remained at risk of relapse.^[1]

Evidence, guidelines and regional differences

^{[1] [4]}

Both definitions use LVEF <45%: ESC 2025 states it as part of the definition, and AHA/ACC/HFSA 2022 says the LVEF is typically <45%.^[1][4]

• They differ on bromocriptine: ESC 2025 says it may be considered in addition to optimal HF treatment to enhance LV recovery (Class IIb, Level B), whereas AHA/ACC/HFSA 2022 gives no row and calls its efficacy and safety uncertain.^[1][4]
• For anticoagulation, the ESC 2025 Class I row recommends therapeutic-dose LMWH in pregnant women with intracardiac thrombus or EF <35%, while the AHA/ACC/HFSA 2022 COR 2b row says anticoagulation may be reasonable in acute HF caused by PPCM with LVEF <30%, from diagnosis until 6 to 8 weeks postpartum, although its efficacy and safety are uncertain.^[1][4]

In Australia and New Zealand

• The NHFA/CSANZ 2018 heart failure guideline has no PPCM-specific recommendation; its section on pregnancy says women with PPCM after a previous pregnancy have increased risks of recurrence, especially with persisting LV systolic dysfunction.^[5]
• It recommends continuing neurohormonal antagonists at target doses in HF with recovered or restored ejection fraction unless a reversible cause has been corrected (strong recommendation for; low quality of evidence).^[5]
• Its practice advice says stopping them can be considered, with specialist advice and close monitoring, in HF with recovered ejection fraction due to PPCM when there is no other indication such as hypertension or vascular disease.^[5]
• Its rationale adds that, unless a reversible cause has been corrected, recovery is likely to represent remission rather than cure in most cases, and stopping these drugs may lead to clinical deterioration.^[5]
• The 2022 Australian consensus statement on the current pharmacological prevention and management of heart failure (Med J Aust, PMID 35908234, not on the register): the census sweep found no PPCM wording.
• The 2023 position statement on improving management for patients with heart failure in Aotearoa New Zealand (PMID 38386858) is not held as text in the evidence caches, so it was not checked for this topic.
• Only the PubMed abstract of the Consensus Statement on Optimisation of Patient Care After Hospitalisation for Acute Heart Failure (PMID 41539881) is held; its full text is not held and was not checked for this topic.
• Only the PubMed abstract of the A summary of the 2023 Society of Obstetric Medicine of Australia and New Zealand (SOMANZ) hypertension in pregnancy guideline (PMID 38763516) is held; its full text is not held and was not checked for this topic.

Guidelines checked for this topic

• Rows on this page come from the ESC 2025 pregnancy, ESC 2023 cardiomyopathies and ESC 2026 heart failure guidelines, with narrative from the ESC 2022 ventricular arrhythmia and ESC 2025 myocarditis and pericarditis guidelines.^{[1][2][3][6][7]}

• North American rows come from the 2022 AHA/ACC/HFSA heart failure guideline (Circulation PMID 35363499), quoted from its JACC co-publication (PMID 35379503); the ANZ row comes from the NHFA/CSANZ 2018 heart failure guideline.^[4][5]

• Study results are quoted from the PubMed abstracts of the 2010 bromocriptine pilot, the 2017 multicentre bromocriptine study, the ESC EORP PPCM registry reports (6 months, 1 year and the bromocriptine analysis) and IPAC.^{[9][8][10][11][12][13]}

• A row called the newer one is so among the guidelines in the census below (census 2026-10-24).

• The 2026 correction to the ESC 2025 pregnancy guideline (PMID 41428090) changes abbreviations, a projection, a misoprostol unit, a Table 12 term and the verapamil dose in the Figure 15 legend; none of these is used on this page.

• The 2026 correction to the ESC 2023 cardiomyopathy guideline (PMID 42605809) corrects childhood HCM values in its Table 4 and an iron-status cell in its Table 22; neither is used on this page.

• ESC 2026 heart failure, used above, refers readers to the ESC 2025 pregnancy guideline for comprehensive and detailed guidance on heart failure in pregnancy.^[3]

• The held guidelines below were checked, and no row from them is used here; each line gives the reason.

• AHA/ACC/HRS 2017 ventricular arrhythmias (PMID 29084731, not on the register): it mentions wearable defibrillators in PPCM only in narrative, with no PPCM row; the ESC 2025 wearable defibrillator row is used instead.

• NHFA/CSANZ 2018 heart failure summary in Med J Aust (PMID 30067937): a summary of the Heart Lung Circ guideline used here, with no PPCM wording.

• ESC 2020 sports cardiology (PMID 32860412): PPCM appears only in a list of possible causes of DCM.

• ACC 2024 myocarditis expert consensus decision pathway (PMID 39665703, not on the register): it mentions PPCM only to compare genetic testing in myocarditis, and it gives no PPCM row.

• ACC/AHA/HRS/ISACHD/SCAI 2025 adult congenital heart disease (PMID 41411375): it states that PPCM is not addressed and refers readers to pertinent guidelines.

• AHA/ACC 2024 perioperative guideline (PMID 39316661): PPCM appears only in a cited article title; its 2026 successor (PMID 42804570) is listed below by held status.

• Myocarditis and pericardial statements other than the ESC 2025 guideline (AHA 2021 myocarditis in children, PMID 34229446; AHA 2020 fulminant myocarditis, PMID 31902242; ESC 2015 pericardial diseases, PMID 26320112) and the cardiomyopathy documents (AHA/ACC 2024 hypertrophic cardiomyopathy, PMID 38718139; ESC 2021 amyloidosis working group, PMID 33825853; Australia–New Zealand 2024 amyloidosis, PMID 38570258): the census sweep found no PPCM wording.

• Rhythm and pacing guidelines (ESC 2021 pacing, PMID 34455430; ACC/AHA/HRS 2018 bradycardia, PMID 30412709; HRS/APHRS/LAHRS 2023 physiologic pacing, PMID 37283271; the 2024 EHRA/HRS/APHRS/LAHRS consensus, PMID 38587017; ESC 2024, PMID 39210723, and ACC/AHA/ACCP/HRS 2023, PMID 38033089, atrial fibrillation; ESC 2019, PMID 31504425, and ACC/AHA/HRS 2015, PMID 26399663, supraventricular tachycardia; ESC 2018, PMID 29562304, and ACC/AHA/HRS 2017, PMID 28280231, syncope): the census sweep found no PPCM wording.

• Coronary guidelines and statements (ESC 2024 chronic coronary syndromes, PMID 39210710; AHA/ACC 2023 chronic coronary disease, PMID 37471501; ESC 2023, PMID 37622654, and ACC/AHA 2025, PMID 40014670, acute coronary syndromes; the NHFA/CSANZ 2025 ACS summary, PMID 41693087; AHA/ACC 2021 chest pain, PMID 34709879; the Fourth, PMID 30571511, and Fifth, PMID 42661425, universal definitions of MI; the AHA 2018, PMID 29472380, and ESC 2018, PMID 29481627, SCAD statements): the census sweep found no PPCM wording.

• Other register and pregnancy-related guidelines (ESC 2020 adult congenital heart disease, PMID 32860028; ESC/EACTS 2025, PMID 40878295, and ACC/AHA 2020, PMID 33332150, valvular heart disease; ESC 2023 endocarditis, PMID 37622656, and diabetes, PMID 37622663; ESC 2022 non-cardiac surgery, PMID 36017553; ESC 2024, PMID 39210715, and AHA/ACC 2025, PMID 40811497, hypertension; ESC 2021 prevention, PMID 34458905; ESC/EAS 2019, PMID 31504418, ESC/EAS 2025, PMID 40878289, and ACC/AHA 2026, PMID 41824552, lipids; ESC 2019, PMID 31504429, and AHA/ACC 2026, PMID 41712677, pulmonary embolism; ESC/ERS 2022 pulmonary hypertension, PMID 36017548, and the 2024 World Symposium reports, PMIDs 39209475 and 39209476; ESC 2024, PMID 39210722, and ACC/AHA 2022, PMID 36322642, aortic and peripheral disease; AHA/ACC/ADA/ASN 2026 cardiovascular-kidney-metabolic, PMID 42263157; ESC 2026 cardiac rehabilitation, PMID 42661418; ACC/AHA 2019 primary prevention, PMID 30879355; AHA 2021 mechanical complications of acute MI, PMID 34126755; AHA/ASA 2024 primary stroke prevention, PMID 39429201; ADA Standards of Care 2026, PMID 41358899; ANZCOR Guideline 11.10; AHA/ACC 2025 competitive sports, PMID 39973614): the census sweep found no PPCM wording.

• AHA 2025 resuscitation special circumstances (PMID 41122889, not on the register): its pregnancy-specific mnemonic is described as highlighting diagnoses unique to, or commonly encountered in, the peripartum period, with cardiomyopathy as one example; it has no PPCM row.

• The documents in this list are not used; each line gives the held status recorded in the census for this topic.

• The 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure (PMID 34447992) are not held as text in the evidence caches, so they were not checked for this topic.

• The 2023 Focused Update of the 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure (PMID 37622666) are not held as text in the evidence caches, so they were not checked for this topic.

• Only the PubMed abstract of the 2023 HRS expert consensus statement on the management of arrhythmias during pregnancy (PMID 37211147) is held; its full text is not held and was not checked for this topic.

• Only the PubMed abstract of the Update on pulmonary embolism in pregnancy and post-partum: The Society of Obstetric Medicine of Australia and New Zealand Position Statement on Pulmonary Embolism in Pregnancy and Post-partum (PMID 34435660) is held; its full text is not held and was not checked for this topic.

• Only the PubMed abstract of the Workup and management of rhythm disorders in myocarditis and inflammatory cardiomyopathy: a clinical consensus statement of the European Heart Rhythm Association and the Heart Failure Association of the ESC, the ESC Working Group on Myocardial & Pericardial Diseases, the European Association of Preventive Cardiology of the ESC, the Heart Rhythm Society, the Asian Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society (PMID 42669046) is held; its full text is not held and was not checked for this topic.

• The Guidelines for the diagnosis and management of hypertrophic cardiomyopathy (PMID 22000299) are not held as text in the evidence caches, so they were not checked for this topic.

• The NHFA/CSANZ Australian Clinical Guidelines for the Diagnosis and Management of Atrial Fibrillation 2018 (PMID 30077228) are not held as text in their version of record, so they were not checked for this topic.

• The NHFA/CSANZ Comprehensive Australian Clinical Guideline for Diagnosing and Managing Acute Coronary Syndromes 2025 (PMID 40180468) is not held as text in its version of record, so it was not checked for this topic.

• The 2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease, in collaboration with the European Renal Association (ERA) (PMID 42661426) are not held as text in their version of record, so they were not checked for this topic.

• Only the PubMed abstract of the 2026 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery (PMID 42804570) is held; its full text is not held and was not checked for this topic.

• The 2018 ESC/EACTS Guidelines on myocardial revascularization (PMID 30165437) are not held as text in the evidence caches, so they were not checked for this topic.

• The 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes (PMID 31504439) are not held as text in the evidence caches, so they were not checked for this topic.

• The 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation (PMID 32860058) are not held as text in the evidence caches, so they were not checked for this topic.

• The 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation (PMID 32860505) are not held as text in the evidence caches, so they were not checked for this topic.

• The 2021 ESC/EACTS Guidelines for the management of valvular heart disease (PMID 34453165) are not held as text in the evidence caches, so they were not checked for this topic.

• The 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization (PMID 34882435) is not held as text in the evidence caches, so it was not checked for this topic.

• The 2022 ESC Guidelines on cardio-oncology (PMID 36017568) are not held as text in the evidence caches, so they were not checked for this topic.

• Only the PubMed abstract of the 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease (PMID 38743805) is held; its full text is not held and was not checked for this topic.

• The 2024 CSANZ Position Statement on Indications, Assessment and Monitoring of Structural and Valvular Heart Disease With Transthoracic Echocardiography in Adults (PMID 38749800) is not held as text in its version of record, so it was not checked for this topic; only its PubMed abstract is quotable.

• The JCS/JPCPHS 2025 Guideline on Pulmonary Hypertension and Pulmonary Embolism/Deep Vein Thrombosis (PMID 42386545) is not held as text in the evidence caches, so it was not checked for this topic.

• Only the PubMed abstract of the European Respiratory Society clinical practice guidelines update for the treatment of pulmonary arterial hypertension (PMID 42705705) is held; its full text is not held and was not checked for this topic.

• Only the PubMed abstract of the Pulmonary hypertension associated with left heart disease (PMID 39209478) is held; its full text is not held and was not checked for this topic.

• Only the PubMed abstract of the 2023 Australian guideline for assessing and managing cardiovascular disease risk (PMID 38623719) is held; its full text is not held and was not checked for this topic.

• The Advanced heart failure: a position statement of the Heart Failure Association of the European Society of Cardiology (PMID 29806100) is not held as text in the evidence caches, so it was not checked for this topic.

• The Guidance for Timely and Appropriate Referral of Patients With Advanced Heart Failure (PMID 34503343) is not held as text in the evidence caches, so it was not checked for this topic.

• The International Society for Heart and Lung Transplantation/Heart Failure Society of America Guideline on Acute Mechanical Circulatory Support (PMID 36754750) is not held as text in the evidence caches, so it was not checked for this topic.

• The Inotropic therapy in patients with advanced heart failure. A clinical consensus statement from the Heart Failure Association of the European Society of Cardiology (PMID 36847113) is not held as text in the evidence caches, so it was not checked for this topic.

• The iCARDIO Alliance Global Implementation Guidelines on Heart Failure 2025 (PMID 40533340) are not held as text in the evidence caches, so they were not checked for this topic.

• Only the PubMed abstract of the Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography and for Heart Failure With Preserved Ejection Fraction Diagnosis: An Update From the American Society of Echocardiography (PMID 40617625) is held; its full text is not held, so it was not checked for this topic.

• Only the PubMed abstract of the Identifying and overcoming barriers to referral in advanced heart failure (PMID 40819957) is held; its full text is not held and was not checked for this topic.

• The Management of aortic stenosis and chronic heart failure: A clinical consensus statement of the Heart Failure Association (HFA) and the European Association of Percutaneous Cardiovascular Interventions (EAPCI) of the ESC (PMID 40948025) is not held as text in the evidence caches, so it was not checked for this topic.

• The Update on heart transplantation: a clinical consensus statement of the Advanced Heart Failure Committee of the Heart Failure Association of the European Society of Cardiology (PMID 42085519) is not held as text in the evidence caches, so it was not checked for this topic.

• The Criteria for the diagnosis of cardiogenic shock-European perspective (PMID 42667225) is not held as text in the evidence caches, so it was not checked for this topic.

• Only the PubMed abstract of the Pharmacological treatment strategies to prevent heart failure across the cardiovascular-kidney-metabolic spectrum: an EJHF Expert Consensus Statement (PMID 42817848) is held; its full text is not held and was not checked for this topic.

Exam pearls

• LVEF threshold in the definition: <45% in ESC 2025 and typically <45% in AHA/ACC/HFSA 2022.^[1][4]
• Recovery in ESC 2025 and the EORP 6-month report means LVEF >50%; ESC 2025 gives 46% recovery at 6 months.^[1][10]
• ESC 2025 Recommendation Table 7 (women with PPCM): counselling about recurrence in a subsequent pregnancy and about contraception, in all cases even after LV recovery, I C; adding at least prophylactic LMWH to bromocriptine IIa C; genetic counselling and testing IIa C; when a reversible course of HF is assumed, HF-guideline treatment for at least 12 months after complete LV recovery IIa C; bromocriptine in addition to optimal HF treatment to enhance LV recovery IIb B; WCD with LVEF <35% IIb C.^[1]
• Anticoagulation thresholds: therapeutic-dose LMWH is recommended in pregnant women with intracardiac thrombus or decreased LV function with EF <35% (ESC 2025, I C); in acute HF caused by PPCM with LVEF <30%, anticoagulation may be reasonable at diagnosis, until 6 to 8 weeks postpartum, although its efficacy and safety are uncertain (AHA/ACC/HFSA 2022, 2b C-LD).^[1][4]
• Bromocriptine dosing in the 2017 multicentre randomized study (63 patients with PPCM and LVEF ≤35%, added to standard HF therapy; primary end point LVEF change from baseline to 6 months): 2.5 mg for 7 days versus 5 mg for 2 weeks then 2.5 mg for 6 weeks; full recovery (LVEF ≥50%) was present in 52% and 68%, with no significant differences between 1-week and 8-week treatment and a trend for better full recovery in the 8-week group.^[8]
• High-risk features (ESC 2025) include LVEF <30%, LV end-diastolic diameter >60 mm, biventricular dysfunction, QT prolongation and delayed diagnosis.^[1]

References13ShowHide

1. [1]De Backer J, et al. 2025 ESC Guidelines for the management of cardiovascular disease and pregnancy. Eur Heart J, 2025.PMID 40878294
2. [2]Arbelo E, et al. 2023 ESC Guidelines for the management of cardiomyopathies. Eur Heart J, 2023.PMID 37622657
3. [3]Køber L, et al. 2026 ESC Guidelines for the management of heart failure. Eur Heart J, 2026.PMID 42661420
4. [4]Heidenreich PA, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol, 2022.PMID 35379503
5. [5]Atherton JJ, et al. National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Guidelines for the Prevention, Detection, and Management of Heart Failure in Australia 2018. Heart Lung Circ, 2018.PMID 30077227
6. [6]Zeppenfeld K, et al. 2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. Eur Heart J, 2022.PMID 36017572
7. [7]Schulz-Menger J, et al. 2025 ESC Guidelines for the management of myocarditis and pericarditis. Eur Heart J, 2025.PMID 40878297
8. [8]Hilfiker-Kleiner D, et al. Bromocriptine for the treatment of peripartum cardiomyopathy: a multicentre randomized study. Eur Heart J, 2017.PMID 28934837
9. [9]Sliwa K, et al. Evaluation of bromocriptine in the treatment of acute severe peripartum cardiomyopathy: a proof-of-concept pilot study. Circulation, 2010.PMID 20308616
10. [10]Sliwa K, et al. Clinical presentation, management, and 6-month outcomes in women with peripartum cardiomyopathy: an ESC EORP registry. Eur Heart J, 2020.PMID 32840318
11. [11]Jackson AM, et al. Outcomes at one year in women with peripartum cardiomyopathy: Findings from the ESC EORP PPCM Registry. Eur J Heart Fail, 2024.PMID 37823238
12. [12]van der Meer P, et al. Bromocriptine treatment and outcomes in peripartum cardiomyopathy: the EORP PPCM registry. Eur Heart J, 2025.PMID 39221911
13. [13]McNamara DM, et al. Clinical Outcomes for Peripartum Cardiomyopathy in North America: Results of the IPAC Study (Investigations of Pregnancy-Associated Cardiomyopathy). J Am Coll Cardiol, 2015.PMID 26293760