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CLINICAL STUDIES

Peripartum cardiomyopathy: analysis of clinical outcome, left ventricular function, plasma levels of cytokines and Fas/APO-1

Karen Sliwa, MD^* , Daniel Skudicky, MD^*, Anette Bergemann, MD^* , Geoffrey Candy, MSc^* , Adrian Puren, MD, PhD and Pinhas Sareli, MD, FACC, FRCP^*

^* Department of Cardiology and Department of Nuclear Medicine, Baragwanath Hospital, Johannesburg, South Africa
Department of Hematology and Molecular Medicine, University of the Witwatersrand, Johannesburg, South Africa

Manuscript received May 11, 1999; revised manuscript received October 5, 1999, accepted November 17, 1999.

Reprint requests and correspondence: Dr. Daniel Skudicky, Department of Cardiology, Baragwanath Hospital, P.O. Bertsham 2013, Johannesburg, South Africa
psareli{at}iafrica.com

OBJECTIVES

1) To evaluate the outcome of patients with peripartum cardiomyopathy (PPC) on current treatment for heart failure, 2) to assess the circulating plasma levels of cytokines and Fas receptors and 3) to identify predictors of prognosis.

BACKGROUND

Previous studies in patients with PPC were done when angiotensin-converting enzyme (ACE) inhibitors and beta-adrenergic blocking agents were not routinely used in heart failure. Inflammatory cytokines play an important role in the pathogenesis and progression of heart failure of other etiologies. However, there is a paucity of data regarding cytokine expression in patients with PPC. Plasma concentrations of Fas receptors (an apoptosis-signalling receptor) have not been reported in this population.

METHODS

We followed prospectively 29 consecutive black women with PPC. All patients were treated with diuretics, digoxin, enalapril and carvedilol. Echocardiograms were performed at baseline and after six months of treatment. Cytokine and soluble Fas/APO-1 plasma levels were measured at baseline.

RESULTS

Tumor necrosis factor-alpha, interleukin-6 and Fas/APO-1 levels were significantly elevated in the study patients compared with 20 healthy volunteers. Eight patients died. sFas/APO-1 levels were significantly higher in patients who died compared with survivors (8.98 ± 4.5 vs. 5.33 ± 3 U/ml, respectively, p = 0.02). At six months, ejection fraction improved from 26.7 ± 10 to 42.7 ± 16%, p = 0.00003, with an increment of more than 10 U in 10 patients (28.1 ± 4 to 51.9 ± 8%, p = 0.000008).

CONCLUSIONS

Cytokine and sFas levels are elevated in patients with PPC. Despite treatment with ACE inhibitors and beta-blockers, mortality remains high. However, in 34% of the patients, left ventricular function almost completely normalized.

Abbreviations and Acronyms   ACE = angiotensin-converting enzyme   FC = functional class   iNOS = inducible nitric oxide   NYHA = New York Heart Association   PPC = peripartum cardiomyopathy   TNF = tumor necrosis factor

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