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Cardiac Disease & Maternity Research Group

Over the last decade a steady increase in institutional maternal mortality rate for cardiac disease in South Africa has been reported. We have found that after non-pregnancy related infections, cardiac disease is the second most common cause of indirect maternal death, with Peripartum cardiomyopathy and complications due to rheumatic heart disease contributing to more than 50% of the cases.  The objective of this research group is to investigate cardiac disease interlinked with pregnancy or the postpartum period.

MEMBERS: Prof. Karen Sliwa ( HICRA), Prof. John Anthony (Dept Obstetrics & Gynaecology, UCT); Dr. Tony Lachmann ( UCT), Dr. Liesl Zϋhlke ( UCT), Dr. Johann Baard ( HICRA), Dr. Feriel Azibani ( HICRA), Mrs Olivia Briton ( HICRA), Prof. Sandrine Lecour ( HICRA), Prof. Denise Hilfiker-Kleiner (Hannover University, GE),  Prof. Michael Böhm ( University of Saarland, Homburg, GE), Dr. Kemi Tibazarwa ( Muhimbili Hospital, Tanzania)

SELECTED PROJECTS:

Peripartum Cardiomyopathy – Current Research

The team has for many years investigated the pathogenesis, etiology, epidemiology and management of a condition, peripartum cardiomyopathy (PPCM), common in African women. PPCM is a disease which develops in previously healthy women, before delivery or in the postpartum period, with a reported mortality of about 25%.

This research has resulted in numerous publications in prestigious journals such as the European Heart Journal (2006, 2014, 2016), Journal of the American College of Cardiology, The Lancet (2006), Cell ( 2007) and Circulation (2011, 2012, 2013). The importance of PPCM contributing to later maternal death has been recently highlighted by us in The Lancet ( 2016). Some aspects of the research forms part of collaborative projects with the University of Hannover, Germany (Prof. Hilfiker-Kleiner) and the University of Saarland, Homburg, Germany (Prof. Böhm).

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Our team reported that a ‘broken’ Prolactin (16kd) causes activation of pro-apoptotic signalling pathways in the heart, leading to left ventricular dilatation and a failing heart.We have investigated the effect of a medication (Bromocryptine) inhibiting prolactin in a randomized study of newly diagnosed patients with PPCM. The positive results of this proof-of-concept pilot was published in Circulation in March 2010. The German team is currently performing a randomized study in Germany. Further research has shown that endothelial microparticles (EMPs), vesicles released from endothelial cellular membranes during cell activation/apoptosis, could directly demonstrate endothelial damage in PPCM (Walenta K, Sliwa K, et al. Circulating microparticles as indicators of peripartum cardiomyopathy. Eur Heart J. 2012). It is still unclear whether hypertension in pregnancy-induced heart failure (PIH-HF) and peripartum cardiomyopathy (PPCM) are disparate clinical entities with different underlying pathogenetic mechanisms, natural histories and disease outcomes, which may sometimes overlap.

PPCM Working Group of Heart Failure Association of European Society of Cardiology

Prof Sliwa’s research translated into the establishment, in 2009, of the Peripartum Cardiomyopathy Working Group, Heart Failure Association of the European Cardiac Society (ESC), chaired by Prof Karen Sliwa and Prof. Johann Bauersachs ( Hannover University). The study group aims:

  • To establish a platform where current knowledge on peripartum cardiomyopathy based on experimental and clinical studies is summarized and regularly up-dated.
  • To raise awareness of this uncommon but devastating problem by promoting sessions at congresses and publishing articles
  • To coordinate the collection and analysis of data internationally for better understanding of the condition. • To meet regularly to discuss and update management strategies with a focus on novel diagnostic and therapeutic approaches.
  • To provide information and contact addresses on our webpage for physicians and patients concerned about PPCM.
  • To initiate and be advocates for the PPCM Registry

 A number of position papers have been published as Sliwa et al. Eur J Heart Failure 2010 and 2014, Bauersachs et al. Eur J Heart Failure 2016.

PPCM EuroObservational Research Program

The PPCM HFA Study group has subsequently leveraged funding for a 1000 patient international registry on PPCM. Prof. K. Sliwa and Prof. Johann Bauersachs are the chairs of the PPCM EuroObservational Research Program ( EORP) on PPCM and the first 500 patients have been recruited. The results of the first 400 patients will be presented at a late breaking trial session at the European Society of Cardiology Congress, Rome, Italy 30th August 2016.

Cardiac Disease in Maternity Cohort Study

The rationale for this cohort study is that the incidence of cardiovascular disease during pregnancy is increasing across the world, resulting in significant morbidity and mortality. Etiology and outcome varies between developing and developed countries. In developing countries, women may have pre-existing disease unmasked by pregnancy (e.g. mitral stenosis due to rheumatic heart disease), a superimposed condition unique to pregnancy (e.g. peripartum cardiomyopathy), or a complication of pregnancy itself (e.g. pregnancy-induced hypertension). There is, however, a lack of data from Africa on this important topic.

This cohort study was initiated by Professor Karen Sliwa at the Cardiac Clinic, Department of Medicine, Groote Schuur Hospital, in conjunction with Professor John Anthony, Department of Obstetrics and Gynaecology, Groote Schuur Hospital, in July 2011.

The objective is to study the natural history of these pregnant women with cardiovascular disease, pre- and postpartum, as well as to identify risk factors and clinical predictors of outcome.

Clinicians are invited to refer patients with a known cardiac condition (e.g. operated congenital heart disease, operated valvular disease) or patients with a suspected cardiac condition, during or post pregnancy, to the Cardiac Disease and Maternity Clinic. More than 300 patients from Cape Town have been entered into the cohort so far.

Serum and plasma are stored at the Hatter Institute. Detailed information on clinical presentation, socio-economic factors, laboratory markers, ECG and echocardiography is collected via a web-based data entry platform. A number of papers have been reported from this cohort. Other sub-studies as e.g. studying the use of loop recorders in pregnant women with arrhythmia ( CDM-REVEAL), funded by Medtronic CRE are under way.

Educating Health Care Workers and Patients in Cardiovascular Disease in Maternity – A multi-media approach implementing cutting edge technology into a culture-sensitive and education and preventative health programme (part of the HEDU-Africa Scheme)

The HEDUAfrica website has become part of the social media community with many Facebook likes (https://www.facebook.com/HeduAfrica) and followers on Twitter (https://twitter.com/HEDUAfrica) at present.

We have developed a multi-media resource that we envision will become a widely available tool for preventing and managing the causes and consequences of cardiovascular diseases in pregnancy and postpartum in Africa. We propose to distribute this resource widely to healthcare providers who manage pregnant women.

This project was initiated by Prof Karen Sliwa, together with the collective expertise of Prof John Anthony (Department of Obstetrics and Gynaecology, Groote Schuur Hospital), Dr Friedrich Thienemann (IIDMM, University of Cape Town) and Christian Diederichs (Integerafrica). It is supported by Prof D Levitt (NHLBI-funded NCD Centre of Excellence at the University of Cape Town) and Dr Vash Mungal-Singh (Heart and Stroke Foundation) and others. This project received funding from the Medtronic Foundation USA (2011-2013)

Pregnancy-Related Obesity prevention Through Education & Communication Technology in AFRICA: The PROTECT-AFRICA STUDY

Synopsis

Educational levels in young African women remain at historical lows. This provides a particular challenge when attempting to optimise the health of mothers and babies through educational strategies. It is estimated that up to one in two pregnant women in urban communities like Soweto are either overweight or obese. In response, our group has pilot data showing the utility of an innovative information technology (IT)-based program to provide readily accessible and understandable health education to this vulnerable population (HEDUAfrica – www.hedu-africa.org).

The PROTECT-AFRICA Study is a multi-centre, appropriately powered, randomised control trial of an integrated, information technology-based educational Intervention programme, to minimise the risk of excessive weight gain in overweight (but not obese) pregnant African women versus an enhanced form of usual care. The study will involve participants from two primary care clinics in Soweto and Cape Town. The primary endpoint will be the proportion of participants who gain > 12kg from 16 weeks to delivery. Key secondary endpoints for the mother is a change in BMI index, change in health knowledge, change in food choices, plasma micronutrient levels (vitamin C and folic acid), body composition, body perception, change in systolic and diastolic BP, and number of caesarean births, treatment for infection post-delivery, the occurrence of obstetric haemorrhages and the effect of health coaching via SMS technology (the SMS content will be based on the content from the video’s on the HeduAfrica site)

A prospective health-economics design analysis will examine the potential cost-benefits of the intervention to significantly reduce the proportion of pregnant women experiencing excessive weight gain (with associated adverse health outcomes) from a health service payer perspective. Data will also be extrapolated to a whole-of-community and health system-wide perspective.

If proven successful and associated with cost-benefits, the PROTECT-AFRICA intervention will provide an important opportunity to limit excessive weight gain in pregnant women in a low-income setting.

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