although peripartum cardiomyopathy ( ppcm ) was first described in 1880 , much is still unknown about its etiology , epidemiology , characteristics , and clinical outcome . the disease has a wide geographic spread , and is an important cause of heart failure ( hf ) in northern nigeria ; it is responsible for as high as 18.7% of all hf cases , and is as important as hypertension as a cause of hf among women . it is believed that left ventricular ( lv ) function recovers in 2341% of ppcm patients over time , and mortality rates also vary widely and could be as high as 16% at 6 months . however , robust outcome data from many parts of the world with high disease prevalence is still lacking . it is , therefore , imperative to study the disease in northern nigeria which has a modest health care capacity , in an attempt to better understand the disease . therefore , the present study aimed to describe the 1-year survival and left ventricular reverse remodeling ( lvrr ) in a cohort of ppcm patients from three referral hospitals in kano , nigeria . this was a longitudinal study carried out in three referral hospitals in kano , nigeria . before the commencement of the study , the research protocol was approved by the research ethics committees of the study centers and kano state hospitals management board . the study conformed to the ethical guidelines of the declaration of helsinki , on the principles for medical research involving human subjects . patients ' inclusion criteria were : ( i ) new diagnosis of ppcm before commencement of medical treatment ; ( ii ) onset of hf symptoms between last few months of pregnancy and first 5 months postpartum ; ( iii ) presenting between last few months of pregnancy and first 9 months postpartum ; ( iv ) at least 18 years of age ; ( v ) contact telephone number , except patients who gave reassurance that they were willing to attend the follow - up visits ; and ( vi ) giving written informed consent . ppcm was defined according to the recommendations of the hf association of the european society of cardiology working group on ppcm , and lv systolic dysfunction was defined as left ventricular ejection fraction ( lvef ) < 50% . at the study sites , physicians and obstetricians were approached and requested to refer all patients with suspected ppcm to the principal investigator ( pi ) for further evaluation at no cost . hospital in - patients with ppcm were clinically evaluated and underwent investigations within the first 48 h of admission . demographic data , relevant aspects of history and physical signs , results of investigations , medications , co - morbid conditions , and complications were included in a detailed questionnaire . for patients who did not have contact telephone number but who agreed to participate , attending the 1 month follow - up with the supervising physician was used as evidence of commitment and for inclusion . all patients were given appointment cards as a reminder , and were also telephoned to be informed of the 6 and 12 months follow - up visits . at the recruitment visit , each subject underwent a 12-lead electrocardiogram ( ecg ) at rest and transthoracic echocardiogram at the study centers according to standard recommendations . the echocardiographic examination was carried out using sonoscape s8 doppler ultrasound system ( shenzhen , china , 2010 ) . other baseline investigations recommended for the management of patients with ppcm were carried out in the laboratories of the study center , including plasma hemoglobin ; serum urea , electrolytes and creatinine ; blood counts ; liver enzymes ; and serum albumin . the pi re - evaluated the patients at 6 and 12 months follow - up , using the same protocol as at recruitment including ecg and echocardiogram examinations , but blood tests were not repeated . systemic hypertension was defined using standard cut - off values for systolic blood pressure ( sbp ) 140 mmhg and or diastolic blood pressure 90 mmhg . anemia was defined as hemoglobin < 12 g / dl , according to the recommendation of the world health organization in nonpregnant women , renal impairment as serum creatinine > 176 mol / l ( > 2 mg / dl ) , hyponatremia as serum sodium < 135 mmol / l , and hypoalbuminemia as serum albumin < 35 g / l . of the standard echocardiographic recordings obtained , lvrr was defined as the presence of both absolute increase in lvef 10.0% and decrease in left ventricular end - diastolic dimension indexed to body surface area ( lveddi ) 33.0 mm / m , while recovered lv systolic function as lvef 55% , at 12 months follow - up . lv diastolic function was defined and graded using transmitral flow and lv myocardial tissue doppler imaging velocities at the mitral annular level as follows : 
 normal lv diastolic function : e : a ratio 12 , deceleration time ( dt ) 160230 ms and e / e ' < 8.grade i left ventricular diastolic dysfunction ( lvdd ) ( impaired myocardial relaxation ) : e : a < 1.0 and dt > 240 ms.grade ii lvdd ( pseudonormalized pattern ) : e : a 11.5 , dt 160230 ms , e ' < 7 cm / s , and e / e ' > 15.0.grade iii lvdd ( restrictive filling ) : e : a > 2.0 , dt < 160 ms , e ' < 7 cm / s , and e / e ' > 15.0 . normal lv diastolic function : e : a ratio 12 , deceleration time ( dt ) 160230 ms and e / e ' < 8 . grade i left ventricular diastolic dysfunction ( lvdd ) ( impaired myocardial relaxation ) : e : a < 1.0 and dt > 240 ms . grade ii lvdd ( pseudonormalized pattern ) : e : a 11.5 , dt 160230 ms , e ' < 7 cm / s , and e / e ' > 15.0 . grade iii lvdd ( restrictive filling ) : e : a > 2.0 , dt < 160 ms , e ' < 7 cm / s , and e / e ' > 15.0 . frequencies , mean , median , and inter - quartile ranges ( iqr ) were used to describe patients ' characteristics . chi - squared , fisher 's exact , student t and mann  whitney u - tests were used to compare categorical and continuous variables as appropriate . spearman correlation coefficient and logistic regression models were used to assess potential associations between lvrr or mortality and variables of interest . two - sided p < 0.05 was considered as the minimum level of statistical significance . before the commencement of the study , the research protocol was approved by the research ethics committees of the study centers and kano state hospitals management board . the study conformed to the ethical guidelines of the declaration of helsinki , on the principles for medical research involving human subjects . patients ' inclusion criteria were : ( i ) new diagnosis of ppcm before commencement of medical treatment ; ( ii ) onset of hf symptoms between last few months of pregnancy and first 5 months postpartum ; ( iii ) presenting between last few months of pregnancy and first 9 months postpartum ; ( iv ) at least 18 years of age ; ( v ) contact telephone number , except patients who gave reassurance that they were willing to attend the follow - up visits ; and ( vi ) giving written informed consent . ppcm was defined according to the recommendations of the hf association of the european society of cardiology working group on ppcm , and lv systolic dysfunction was defined as left ventricular ejection fraction ( lvef ) < 50% . at the study sites , physicians and obstetricians were approached and requested to refer all patients with suspected ppcm to the principal investigator ( pi ) for further evaluation at no cost . hospital in - patients with ppcm were clinically evaluated and underwent investigations within the first 48 h of admission . demographic data , relevant aspects of history and physical signs , results of investigations , medications , co - morbid conditions , and complications were included in a detailed questionnaire . for patients who did not have contact telephone number but who agreed to participate , attending the 1 month follow - up with the supervising physician was used as evidence of commitment and for inclusion . all patients were given appointment cards as a reminder , and were also telephoned to be informed of the 6 and 12 months follow - up visits . at the recruitment visit , each subject underwent a 12-lead electrocardiogram ( ecg ) at rest and transthoracic echocardiogram at the study centers according to standard recommendations . the echocardiographic examination was carried out using sonoscape s8 doppler ultrasound system ( shenzhen , china , 2010 ) . other baseline investigations recommended for the management of patients with ppcm were carried out in the laboratories of the study center , including plasma hemoglobin ; serum urea , electrolytes and creatinine ; blood counts ; liver enzymes ; and serum albumin . the pi re - evaluated the patients at 6 and 12 months follow - up , using the same protocol as at recruitment including ecg and echocardiogram examinations , but blood tests were not repeated . systemic hypertension was defined using standard cut - off values for systolic blood pressure ( sbp ) 140 mmhg and or diastolic blood pressure 90 mmhg . anemia was defined as hemoglobin < 12 g / dl , according to the recommendation of the world health organization in nonpregnant women , renal impairment as serum creatinine > 176 mol / l ( > 2 mg / dl ) , hyponatremia as serum sodium < 135 mmol / l , and hypoalbuminemia as serum albumin < 35 g / l . of the standard echocardiographic recordings obtained , lvrr was defined as the presence of both absolute increase in lvef 10.0% and decrease in left ventricular end - diastolic dimension indexed to body surface area ( lveddi ) 33.0 mm / m , while recovered lv systolic function as lvef 55% , at 12 months follow - up . lv diastolic function was defined and graded using transmitral flow and lv myocardial tissue doppler imaging velocities at the mitral annular level as follows : 
 normal lv diastolic function : e : a ratio 12 , deceleration time ( dt ) 160230 ms and e / e ' < 8.grade i left ventricular diastolic dysfunction ( lvdd ) ( impaired myocardial relaxation ) : e : a < 1.0 and dt > 240 ms.grade ii lvdd ( pseudonormalized pattern ) : e : a 11.5 , dt 160230 ms , e ' < 7 cm / s , and e / e ' > 15.0.grade iii lvdd ( restrictive filling ) : e : a > 2.0 , dt < 160 ms , e ' < 7 cm / s , and e / e ' > 15.0 . normal lv diastolic function : e : a ratio 12 , deceleration time ( dt ) 160230 ms and e / e ' < 8 . grade i left ventricular diastolic dysfunction ( lvdd ) ( impaired myocardial relaxation ) : e : a < 1.0 and dt > 240 ms . grade ii lvdd ( pseudonormalized pattern ) : e : a 11.5 , dt 160230 ms , e ' < 7 cm / s , and e / e ' > 15.0 . grade iii lvdd ( restrictive filling ) : e : a > 2.0 , dt < 160 ms , e ' < 7 cm / s , and e / e ' > 15.0 . frequencies , mean , median , and inter - quartile ranges ( iqr ) were used to describe patients ' characteristics . chi - squared , fisher 's exact , student t and mann  whitney u - tests were used to compare categorical and continuous variables as appropriate . spearman correlation coefficient and logistic regression models were used to assess potential associations between lvrr or mortality and variables of interest . two - sided p < 0.05 was considered as the minimum level of statistical significance . a total of 72 patients were referred to the investigators with a diagnosis of ppcm based on clinical features and findings on chest radiograph . after further evaluation including echocardiography , 18 subjects ( 25.0% ) were excluded and the remaining 54 ( 75.0% ) were confirmed to have ppcm , and all were of hausa  fulani ethnic group [ figure 1 ] . of these 54 patients , 29 had contact phone numbers and were contacted and the remaining 25 ( 46.3% ) did not have contact phone numbers , 4 ( 16.0% ) of whom qualified for follow - up . overall , therefore , 33 patients were followed up as shown in figure 1 . when the 21 patients who did not have contact phone numbers and did not attend follow - up were compared with the 33 followed up patients , their baseline characteristics were similar ( p > 0.05 ) except for the lower mean hemoglobin in the former group ( 11.5  2.0 g / dl ) compared with the latter group ( 12.8  1.6 g / dl ) ( p = 0.026 ) . flowchart of recruitment and follow - up of patients the age of the patients ranged between 18 and 45 years with a mean of 26.6  6.7 years , and 19 of them ( 35.2% ) were between 18 and 20 years , 24 ( 44.5% ) between 20 and 30 years , and the remaining 11 ( 20.4% ) were older than 30 years . no patient had a history of smoking , diabetes mellitus , alcohol drinking , stroke , or morbid arrhythmias . one patient had lv thrombus and developed lower limb gangrene needing bilateral below knee amputations . screening for human immunodeficiency virus was not carried out and none of the recruited patients was known to have the disease . patients ' body mass index ( bmi ) < 18.5kg / m ( under - weight ) was found in 14 ( 25.9% ) , 18.524.9 kg / m ( normal body weight ) in 29 ( 53.7% ) , 25.029.9 kg / m in 8 ( 14.8% ) , and 30.05 kg / m in only 2 ( 3.7% ) patients . nine ( 16.7% ) patients had hypotension ( sbp < 100 mmhg ) and 25 ( 46.3% ) had pregnancy - induced hypertension at presentation . two patients became pregnant again before the 6 months follow - up , and both survived follow - up ; their lvef increased from 43.5  5.0% at baseline to 52.5  5.0% and 54.5  3.5% at 6 and 12 months follow - up , respectively . of the 17 survivors at 12 months follow - up , 5 ( 29.4% ) had recovered lv systolic function ( lvef 55% ) , 10 ( 58.8% ) had increased lvef of at least 10% , and 8 ( 47.1% ) had reduced lveddi 33.0 mm / m [ table 1 ] . there was no relationship between the use of angiotensin converting enzyme inhibitors ( acei ) , angiotensin ii receptor blockers ( arb ) , beta - blockers ( p = 0.203 ) , other medications or echocardiographic variables ( p > 0.05 ) and lvrr ( p = 0.325 ) , in binary logistic regression models . characteristics of patients with and without lv reverse remodeling of note , mean lvef , lvedd , as well as left atrial ( la ) size and new york heart association ( nyha ) functional class all significantly improved at 6 months ( p < 0.05 ) , but the differences between the 6 and 12 months follow - upvalues were not statistically significant ( p > 0.05 ) [ figure 2a ] . furthermore , patients with lvrr had significantly shorter qrs duration than those without ( p = 0.003 ) . at 12 months , qrs duration correlated negatively with lvef ( r = 0.602 ; p = 0.018 ) and positively with left ventricular mass index ( lvmi ) ( r = 0.612 ; p = 0 , 012 ) . however , these associations were not significant ( p > 0.05 ) at baseline or 6 months follow - up . ( a)pattern of changes in left ventricular ejection fraction and end - diastolic dimension , left atrial dimension , and symptoms in peripartum cardiomyopathy patients over 1-year , ( b ) pattern of changes in left ventricular diastolic dysfunction in peripartum cardiomyopathy patients over 1-year the pattern and changes over 1-year of the lvdd are illustrated in figure 2b . at baseline , lvdd was found in a total of 48 patients ( 88.9% ) and 6 ( 11.1% ) had normal function . of the patients with lvdd , 44 ( 91.7% ) had grade iii , 1 ( 2.1% ) had grade ii , while the remaining 3 ( 6.3% ) had grade i lvdd . at 6 months follow - up , 12 patients ( 48.0% ) had normal lv diastolic function and 13 ( 52.0% ) had lvdd ( p = 0.003 compared with baseline results ) , while at 12 months 6 patients ( 35.3% ) had normal lv diastolic function and 11 ( 64.7% ) had lvdd ( p = 0.02 compared with baseline results ) . however , the prevalence of lvdd at 6 and 12 months follow - ups did not differ ( p = 0.414 ) . of the 33 patients followed up , 12 died ( 36.4% ) , 8 ( 66.7% ) within the first 6 months and the remaining 4 ( 33.3% ) before the 12 months follow - up , four patients were lost to follow - up ( 12.1% ) , and 17 ( 51.5% ) completed the follow - up [ figure 1 ] . the baseline characteristics of the 17 survivors ( 58.6% ) were similar to the deceased ( 41.4% ) except for lower serum albumin and lvmi , and higher plasma hemoglobin ( p < 0.05 ) [ table 2 ] . the mean nyha class for survivors reduced from 2.53  0.80 at baseline to 1.47  0.62 at 1-year follow - up ( p < 0.001 ) . none of these or other variables including lvrr predicted mortality in the regression models ( > 0.05 ) . the median survival time from diagnosis for the deceased patients was 20.0 ( iqr = 926 ) weeks . the age of the patients ranged between 18 and 45 years with a mean of 26.6  6.7 years , and 19 of them ( 35.2% ) were between 18 and 20 years , 24 ( 44.5% ) between 20 and 30 years , and the remaining 11 ( 20.4% ) were older than 30 years . no patient had a history of smoking , diabetes mellitus , alcohol drinking , stroke , or morbid arrhythmias . one patient had lv thrombus and developed lower limb gangrene needing bilateral below knee amputations . screening for human immunodeficiency virus was not carried out and none of the recruited patients was known to have the disease . patients ' body mass index ( bmi ) < 18.5kg / m ( under - weight ) was found in 14 ( 25.9% ) , 18.524.9 kg / m ( normal body weight ) in 29 ( 53.7% ) , 25.029.9 kg / m in 8 ( 14.8% ) , and 30.05 kg / m in only 2 ( 3.7% ) patients . nine ( 16.7% ) patients had hypotension ( sbp < 100 mmhg ) and 25 ( 46.3% ) had pregnancy - induced hypertension at presentation . two patients became pregnant again before the 6 months follow - up , and both survived follow - up ; their lvef increased from 43.5  5.0% at baseline to 52.5  5.0% and 54.5  3.5% at 6 and 12 months follow - up , respectively . of the 17 survivors at 12 months follow - up , 5 ( 29.4% ) had recovered lv systolic function ( lvef 55% ) , 10 ( 58.8% ) had increased lvef of at least 10% , and 8 ( 47.1% ) had reduced lveddi 33.0 mm / m [ table 1 ] . there was no relationship between the use of angiotensin converting enzyme inhibitors ( acei ) , angiotensin ii receptor blockers ( arb ) , beta - blockers ( p = 0.203 ) , other medications or echocardiographic variables ( p > 0.05 ) and lvrr ( p = 0.325 ) , in binary logistic regression models . characteristics of patients with and without lv reverse remodeling of note , mean lvef , lvedd , as well as left atrial ( la ) size and new york heart association ( nyha ) functional class all significantly improved at 6 months ( p < 0.05 ) , but the differences between the 6 and 12 months follow - upvalues were not statistically significant ( p > 0.05 ) [ figure 2a ] . furthermore , patients with lvrr had significantly shorter qrs duration than those without ( p = 0.003 ) . at 12 months , qrs duration correlated negatively with lvef ( r = 0.602 ; p = 0.018 ) and positively with left ventricular mass index ( lvmi ) ( r = 0.612 ; p = 0 , 012 ) . however , these associations were not significant ( p > 0.05 ) at baseline or 6 months follow - up . ( a)pattern of changes in left ventricular ejection fraction and end - diastolic dimension , left atrial dimension , and symptoms in peripartum cardiomyopathy patients over 1-year , ( b ) pattern of changes in left ventricular diastolic dysfunction in peripartum cardiomyopathy patients over 1-year the pattern and changes over 1-year of the lvdd are illustrated in figure 2b . at baseline , lvdd was found in a total of 48 patients ( 88.9% ) and 6 ( 11.1% ) had normal function . of the patients with lvdd , 44 ( 91.7% ) had grade iii , 1 ( 2.1% ) had grade ii , while the remaining 3 ( 6.3% ) had grade i lvdd . at 6 months follow - up , 12 patients ( 48.0% ) had normal lv diastolic function and 13 ( 52.0% ) had lvdd ( p = 0.003 compared with baseline results ) , while at 12 months 6 patients ( 35.3% ) had normal lv diastolic function and 11 ( 64.7% ) had lvdd ( p = 0.02 compared with baseline results ) . however , the prevalence of lvdd at 6 and 12 months follow - ups did not differ ( p = 0.414 ) . of the 33 patients followed up , 12 died ( 36.4% ) , 8 ( 66.7% ) within the first 6 months and the remaining 4 ( 33.3% ) before the 12 months follow - up , four patients were lost to follow - up ( 12.1% ) , and 17 ( 51.5% ) completed the follow - up [ figure 1 ] . the baseline characteristics of the 17 survivors ( 58.6% ) were similar to the deceased ( 41.4% ) except for lower serum albumin and lvmi , and higher plasma hemoglobin ( p < 0.05 ) [ table 2 ] . the mean nyha class for survivors reduced from 2.53  0.80 at baseline to 1.47  0.62 at 1-year follow - up ( p < 0.001 ) . none of these or other variables including lvrr predicted mortality in the regression models ( > 0.05 ) . the median survival time from diagnosis for the deceased patients was 20.0 ( iqr = 926 ) weeks . the present study describes the 1-year mortality and lvrr of a cohort of ppcm patients recruited from three referral hospitals in kano , nigeria . of the 33 patients ( 80% < 30 years old ) followed up , 47.1% had lvrr and 29.4% recovered lv systolic function . of the 29 remaining patients after excluding the four lost to follow - up , 17 survived ( 58.6% ) and 12 died ( 41.4% ) during the follow - up period , with a median survival time of 20 weeks . of the 17 survivors at 12 months follow - up , 47.1% satisfied the criteria for lvrr while 29.4% recovered lv systolic function . there was no relationship between the use of hf medications or other variables and lvrr in the regression models . in addition , significant improvement in mean lvef , lvedd , la size , lvdd , and nyha functional class had already manifested at 6 months , with no further significant improvement at 12 months follow - up . lvdd was similar ; showing a maximum fall in its prevalence from 89% at baseline to 52% at 6 months follow - up . therefore , lv recovery in our ppcm patients involved both systolic and diastolic functions , with maximum improvement achieved at 6 months follow - up in most patients , independent of aceis , arbs , and beta - blockers . however , almost all the patients were treated with frusemide , spironolactone , and digoxin , as a treatment for hf . our findings on lvrr seem to be similar to those previously reported from south africa ( 21% ) and haiti ( 28% ) but lower than what was reported from usa ( 54% ) likely because of the differences in the level of health care between the three countries . furthermore , the achievement of maximum recovery within 6 months in our cohort of patients is also supported by fett et al . and elkayam . finally , our inability to identify predictors of recovery of lv function or reverse remodeling , including hf medications , was similarly reported by fett et al . however , blauwet et al . found older age and smaller lv end - systolic dimension to be significant predictors of lv recovery among south africans . in addition , our results show that patients with lvrr had significantly shorter qrs duration than those without , and qrs duration correlated with lvef and with lvmi , but only at 1-year follow - up . thus , aside from  mechanical remodeling ,  our results also show that  electrical remodeling  does occur in ppcm , and is likely related to the progression or otherwise of the lv disease . similar observations were previously made by shamim et al . among patients with dilated and ischemic cardiomyopathies . progressive lv disease eventually results in increased myocardial stiffness and a rise in diastolic pressures . the resulting increase in lv filling pressures and consequent ischemia of the subendocardium depolarization  delay , which if prolonged could result in subendocardial fibrosis and permanent conduction disturbance . thus , in dilated and dysfunctioning ventricles , progressive broadening of the qrs complex can be taken as a marker of worsening of the ventricular disease . of the 29 patients with complete 12 months follow - up , 58.6% had significantly lower serum albumin and lvmi , and higher plasma hemoglobin than the deceased . however , none of these or other variables could predict mortality in regression models . two - thirds of the deaths occurred within 6 months of diagnosis while the remaining one - third died before the 12 months follow - up . much lower mortality rates of 13.0% over 6 months in south africa , 15.3% over 2 years in haiti , and 28.0% over 5 years in usa , respectively , have been reported . although some researchers did not identify any predictors of mortality in agreement with our finding , others reported inconsistent predictors of mortality including younger age at diagnosis , lower bmi , and echocardiographic variables . it is clearly difficult to compare mortality results between studies given the varying follow - up times and several other challenges including the possible strong influence of sociopolitical crises on the mortality . similar to our findings , 53.3% of those who died in the haiti study did so within 60 days after diagnosis . whitehead et al . also reported that in a cohort of ppcm patients in the usa , 18% of deaths occurred within 1-week and 87% within 6 months of diagnosis . therefore , most of the mortality in ppcm , as well as recovery , seem to occur within 6 months of diagnosis . although the reasons for these observations are not clear , they seem to give hope to patients of better outcomes once they survive the first 6 months of the disease . it is , therefore , imperative that patients are supported with optimal medical treatment to be able to survive the first 6 months of the disease . first , natriuretic peptides and other biomarkers of hf were not assessed because the tests were not readily available at the study centers . second , 21 out of 54 patients could not be followed up because they lacked phone numbers and so could not be contacted , and did not turn up for follow - up in spite of adequate counseling . however , these patients had similar baseline characteristics as those followed up except for their lower mean hemoglobin levels . of the 17 survivors at 12 months follow - up , 47.1% satisfied the criteria for lvrr while 29.4% recovered lv systolic function . there was no relationship between the use of hf medications or other variables and lvrr in the regression models . in addition , significant improvement in mean lvef , lvedd , la size , lvdd , and nyha functional class had already manifested at 6 months , with no further significant improvement at 12 months follow - up . lvdd was similar ; showing a maximum fall in its prevalence from 89% at baseline to 52% at 6 months follow - up . therefore , lv recovery in our ppcm patients involved both systolic and diastolic functions , with maximum improvement achieved at 6 months follow - up in most patients , independent of aceis , arbs , and beta - blockers . however , almost all the patients were treated with frusemide , spironolactone , and digoxin , as a treatment for hf . our findings on lvrr seem to be similar to those previously reported from south africa ( 21% ) and haiti ( 28% ) but lower than what was reported from usa ( 54% ) likely because of the differences in the level of health care between the three countries . furthermore , the achievement of maximum recovery within 6 months in our cohort of patients is also supported by fett et al . and elkayam . finally , our inability to identify predictors of recovery of lv function or reverse remodeling , including hf medications , was similarly reported by fett et al found older age and smaller lv end - systolic dimension to be significant predictors of lv recovery among south africans . in addition , our results show that patients with lvrr had significantly shorter qrs duration than those without , and qrs duration correlated with lvef and with lvmi , but only at 1-year follow - up . thus , aside from  mechanical remodeling ,  our results also show that  electrical remodeling  does occur in ppcm , and is likely related to the progression or otherwise of the lv disease . similar observations were previously made by shamim et al . among patients with dilated and ischemic cardiomyopathies . progressive lv disease eventually results in increased myocardial stiffness and a rise in diastolic pressures . the resulting increase in lv filling pressures and consequent ischemia of the subendocardium depolarization  delay , which if prolonged could result in subendocardial fibrosis and permanent conduction disturbance . thus , in dilated and dysfunctioning ventricles , progressive broadening of the qrs complex can be taken as a marker of worsening of the ventricular disease . of the 29 patients with complete 12 months follow - up , 58.6% had significantly lower serum albumin and lvmi , and higher plasma hemoglobin than the deceased . however , none of these or other variables could predict mortality in regression models . two - thirds of the deaths occurred within 6 months of diagnosis while the remaining one - third died before the 12 months follow - up . much lower mortality rates of 13.0% over 6 months in south africa , 15.3% over 2 years in haiti , and 28.0% over 5 years in usa , respectively , have been reported . although some researchers did not identify any predictors of mortality in agreement with our finding , others reported inconsistent predictors of mortality including younger age at diagnosis , lower bmi , and echocardiographic variables . it is clearly difficult to compare mortality results between studies given the varying follow - up times and several other challenges including the possible strong influence of sociopolitical crises on the mortality . similar to our findings , 53.3% of those who died in the haiti study did so within 60 days after diagnosis . whitehead et al . also reported that in a cohort of ppcm patients in the usa , 18% of deaths occurred within 1-week and 87% within 6 months of diagnosis . therefore , most of the mortality in ppcm , as well as recovery , seem to occur within 6 months of diagnosis . although the reasons for these observations are not clear , they seem to give hope to patients of better outcomes once they survive the first 6 months of the disease . it is , therefore , imperative that patients are supported with optimal medical treatment to be able to survive the first 6 months of the disease . , natriuretic peptides and other biomarkers of hf were not assessed because the tests were not readily available at the study centers . second , 21 out of 54 patients could not be followed up because they lacked phone numbers and so could not be contacted , and did not turn up for follow - up in spite of adequate counseling . however , these patients had similar baseline characteristics as those followed up except for their lower mean hemoglobin levels . this study has described the lvrr and 1-year survival of ppcm in three referral hospitals in kano , nigeria . lvrr occurred in almost half the patients at 6 months but was not predicted by any clinical or echocardiographic variable . our results also showed that lvrr was associated with shorter qrs duration which correlated with lvef and lvmi at 1-year follow - up , thus signifying  electrical remodeling  in ppcm . finally , none of the variables predicted the 41.4% mortality , of which two - thirds occurred before the first 6 months follow - up . the authors feel strongly that further studies should be carried out to better understand the disease .
background : peripartum cardiomyopathy ( ppcm ) is common in north - western nigeria . 
 this study aimed to describe the 1-year survival and left ventricular reverse remodeling ( lvrr ) in a group of patients with ppcm from three referral hospitals in kano , nigeria.methods:ppcm was defined according to recommendations of the heart failure ( hf ) association of the european society of cardiology working group on ppcm . 
 lvrr was defined as absolute increase in left ventricular ejection fraction ( lvef ) by 10.0% and decrease in left ventricular ( lv ) end - diastolic dimension indexed to body surface area 33.0 mm / m2 , while recovered lv systolic function as lvef 55% , at 12 months follow-up.results:a total of 54 newly diagnosed ppcm patients with mean age of 26.6  6.7 years , presented with classical features of predominantly left - sided hf and 33 of them qualified for follow - up . of the 17 survivors at 12 months , 8 patients ( 47.1% ) satisfied the criteria for lvrr , of whom 5 ( 29.4% ) had recovered lv systolic function ( lvef 55% ) , but lvrr was not predicted by any variable in the regression models . 
 the prevalence of normal lv diastolic function increased from 11.1% at baseline to 35.3% at 12 months ( p = 0.02 ) . at 1-year follow - up , 
 41.4% of patients had died ( two - thirds of them within the first 6 months ) , but mortality was not predicted by any variable including lvrr.conclusions:in kano , ppcm patients had modest lvrr but high mortality at 1-year . 
 further studies should be carried out to identify reasons for the high mortality and how to curb it .