Peripartum Cardiomyopathy in Black Women: Warning Signs

Peripartum cardiomyopathy (PPCM) is a form of heart failure where the heart muscle weakens and the main pumping chamber enlarges, usually in the last month of pregnancy or within five months after delivery. The heart can no longer pump enough blood, so fluid backs up into the lungs and body. For Black women, the stakes are higher at every step: higher incidence, earlier onset, more severe disease at diagnosis, lower recovery, and a larger share of late maternal deaths.

PPCM is a dilated cardiomyopathy, meaning the left ventricle stretches and weakens so it cannot squeeze blood out effectively. Doctors measure this with the ejection fraction, the percentage of blood the heart pushes out with each beat. A healthy heart sits between 50% and 70%. A diagnosis generally requires an ejection fraction below 45%, appearing late in pregnancy or in the months after delivery, in a woman with no known heart disease and no other explanation.

It is rare overall but devastating when missed. Cardiomyopathy is the leading cause of death in the late postpartum period, the window from 43 days to a year after delivery, accounting for roughly 45% of pregnancy-related deaths in that stretch, according to CDC data. That late timing matters: many women have left the hospital, finished their six-week checkup, and assume the danger has passed.

Black women carry a disproportionate share of PPCM. In a single-center analysis published in the Journal of the American College of Cardiology, the incidence was 340 cases per 100,000 deliveries among Black women versus 24 per 100,000 among non-Black women, a roughly 15-fold higher unadjusted risk (Gentry et al., 2010, PMID 20170791). Even after adjusting for age, blood pressure, and other risk factors in national datasets, Black race remains an independent risk factor for developing the disease.

The gap does not close after diagnosis. In a study of 220 women at the University of Pennsylvania, Black women were diagnosed younger (mean 27.6 vs 31.7 years), were more likely to arrive with an ejection fraction below 30%, were more likely to get worse after diagnosis, and were nearly twice as likely to fail to recover heart function (Irizarry et al., JAMA Cardiology, 2017, PMID 29049825). When Black women did recover, it took about twice as long: a median of 265 days versus 125 days.

Later research from the multicenter Investigations of Pregnancy-Associated Cardiomyopathy (IPAC) study found the worst outcomes clustered in Black women who did not have a hypertensive disorder of pregnancy. That subgroup presented later, showed more cardiac remodeling, recovered less, and had more major events at one year than other women (Polsinelli et al., American Heart Journal, 2024, PMID 38996860). The pattern points away from a simple genetic story and toward delayed recognition and unequal care.

PPCM sits inside the broader Black maternal-health emergency. Black women died at 44.8 maternal deaths per 100,000 live births in 2024, roughly three times the rate for white women, per the National Center for Health Statistics. The CDC has found about three in five pregnancy-related deaths are preventable, and cardiomyopathy is a leading cardiovascular cause. PPCM is part of why the postpartum heart deserves the same attention as the postpartum uterus. The same disparity shows up across cardiac care: see our reporting on why heart failure hits Black patients earlier and harder.

The symptoms of heart failure look almost identical to normal late pregnancy and recovery. Shortness of breath, swollen ankles, fatigue, and a racing heart are expected when you are carrying a baby or healing from birth. That overlap is the trap, and a woman or her clinician can write off the warning signs as ordinary postpartum exhaustion.

Bias compounds the delay. Black women's distress is more often minimized, and concerns get dismissed as anxiety. When the late-postpartum window stretches past the standard six-week visit, there may be no scheduled appointment left to catch it. The result is later diagnosis at a point when the heart is already more damaged, which is exactly what the disparity data show. The fix is specific: when breathlessness or swelling is new, worsening, or out of proportion, it gets worked up, not waved off.

These point to fluid backing up because the heart is failing. One alone can be benign; the combination, or any that is new and worsening, needs evaluation:

• Shortness of breath with light activity, or worse, at rest
• Trouble breathing when lying flat, needing extra pillows to sleep, or waking up gasping
• A persistent dry cough, sometimes worse at night
• Swelling in the feet, ankles, legs, or sudden weight gain from fluid
• A racing or pounding heartbeat, or palpitations
• Severe fatigue beyond normal new-parent tiredness, dizziness, or fainting

Two tests carry the diagnosis. A BNP or NT-proBNP blood test measures a hormone the heart releases when it is under strain; these levels do not rise much in normal pregnancy, so a high result is a red flag. An echocardiogram, an ultrasound of the heart, shows the ejection fraction and whether the left ventricle is enlarged and pumping poorly. An ejection fraction below 45% with no other cause confirms PPCM. A normal ECG does not rule it out, so do not let a normal heart tracing end the workup if symptoms persist.

Treatment is guideline-directed heart failure therapy, adjusted for whether you are still pregnant or breastfeeding. During pregnancy, ACE inhibitors and ARBs are avoided because they harm the fetus; hydralazine and nitrates are the safer substitutes, alongside beta-blockers and careful diuretics for fluid. After delivery, the standard regimen comes into play, and ACE inhibitors such as captopril and enalapril are considered compatible with breastfeeding, so a PPCM diagnosis does not automatically mean you must stop nursing. Discuss each medication with your cardiologist.

A weakened heart raises the risk of blood clots, so anticoagulation is often added when the ejection fraction is very low or a clot is seen on imaging. Bromocriptine, which stops lactation, is used in some cases and is always paired with a blood thinner because of clot risk; doctors weigh it case by case rather than universally. This is a cardiology condition, and it should be co-managed by a cardiologist, ideally one experienced in pregnancy-related heart disease.

Many women recover meaningful heart function within six to twelve months, but recovery is not guaranteed, and Black women recover less often and more slowly. Some are left with lasting heart failure that needs lifelong medication, a device, or rarely a transplant. Follow-up echocardiograms track whether your ejection fraction returns toward normal.

Recovery status shapes the decision about another pregnancy. A subsequent pregnancy carries a real risk of relapse: studies report heart-failure recurrence around 24% in women whose function had recovered and roughly 36% in those whose function had not fully normalized, with higher risk of severe deterioration when the heart never returned to baseline. Anyone with a PPCM history should have a preconception consultation with a cardiologist before trying again, and reliable contraception until that conversation happens.

You know your body. If something feels wrong after delivery, push for the workup even if you have been reassured. Say the words out loud: I want my heart checked, I want a BNP and an echocardiogram. Bring someone who can advocate if you are too exhausted to. A clinician who takes your symptoms seriously the first time is part of the treatment.

If you want a cardiologist or maternal-health provider who listens, you can find a Black or Black-serving clinician in our directory. For the full set of red flags in the weeks after birth, read our guide to postpartum warning signs Black mothers should never ignore.