Sarojini A, Sai Ravi Shanker A, Anitha M
Department of Obstetrics & Gynaecology, Narayana Medical College, Nellore, India.
Department of Cardiology, Narayana Medical College, Nellore, India.
J Obstet Gynaecol India. 2013 Aug;63(4):234-9. doi: 10.1007/s13224-013-0428-9. Epub 2013 Aug 14.
AIM/OBJECTIVE: Peripartum cardiomyopathy (PPCM) is a disorder of unknown etiology in which symptoms of heart failure occur between the last month of pregnancy and 5 months post-partum. These findings prompted us to carry out a more detailed study aimed at correlating plasma levels of C-reactive protein TNF-α and IL-6 as prognostic value for major clinical in-hospital events and 6-month follow-up in patients with PPCM.
After ethical clearance, in the present prospective case-control study, a total of 86 subjects were enrolled [patients (n = 46) and controls (n = 40)]. After checking for the inclusion and exclusion criteria, informed consent was obtained and patients were enrolled. The details of history of pre-eclampsia and mode of delivery were obtained from the patients. The history of onset of symptoms and signs was recorded at the first presentation and at 6 months. Clinical assessment, echocardiography, and blood analysis were done at baseline and after 6 months of standard therapy. All patients received treatment with diuretics and the ACE inhibitor (ramipril), Carvedilol if not contraindicated, and inotropic support inj-Dobutamine. Inflammatory markers (C-reactive protein, TNF-α, and IL-6) were measured at baseline and at 6 months. Data were analyzed using the SAS version 9.1 statistical program.
The characteristics of the study population at first presentation to the cardiac clinic are similar (compared with controls): 0.91 % of the study patients were diagnosed as PPCM patients for the first time and 49 % patients presented within one month after delivery. C-reactive protein (22 vs 08 mg/dl, p < 0.05), TNF-α (9.6 vs 3.2 pg/dl, p < 001), and IL-6 (73.19 ± 34.4 vs 31.52 ± 8.83 pg/dl, p < 0.005) were significantly abnormal, and these patients showed significantly higher LV dimensions, LV EDD (61.6 ± 7.1 vs 46 ± 9 mm p < 0.004) LV ESD (53.1 ± 7 vs 32 ± 8, p < 0.005), and significantly lower echocardiographic left ventricular ejection fraction (LVEF) (25.9 ± 8.2 vs 55 ± 12 p < 0.001) and correlate well with NYHA FC and death. LVEF improved from 25.9 ± 8.2 to 42.9 + 13.6 % at 6 months (p < 0.0001). Patients who completed 6 months of standard care showed a significant reduction of heart rate, LV dimensions, and NYHA FC (p < 0.001). However, normalization of LVEF (>50 %) was only observed in 11 (35 %) patients. Seven patients died within 6 months of diagnoses and eight patients were lost to follow-up.
Plasma markers of inflammation were significantly elevated in PPCM patients and correlated with increased LV dimensions and lower EF at presentation. Baseline CRP, IL-6, TNF-α, and higher NYHA FC were the only predictors of mortality. These results contribute to inflammation which may contribute to the pathogenesis of PPCM and its complications and predictors of mortality.
围产期心肌病(PPCM)是一种病因不明的疾病,其心力衰竭症状出现在妊娠最后一个月至产后5个月之间。这些发现促使我们开展一项更详细的研究,旨在将血浆C反应蛋白、TNF-α和IL-6水平与PPCM患者主要住院临床事件及6个月随访的预后价值相关联。
在获得伦理批准后,在本前瞻性病例对照研究中,共纳入86名受试者[患者(n = 46)和对照组(n = 40)]。在检查纳入和排除标准后,获得知情同意并纳入患者。从患者处获取先兆子痫病史和分娩方式的详细信息。在首次就诊时和6个月时记录症状和体征的发作史。在基线和标准治疗6个月后进行临床评估、超声心动图检查和血液分析。所有患者接受利尿剂和ACE抑制剂(雷米普利)治疗,若无禁忌证则使用卡维地洛,以及使用多巴酚丁胺进行强心支持治疗。在基线和6个月时测量炎症标志物(C反应蛋白、TNF-α和IL-6)。使用SAS 9.1统计程序分析数据。
首次到心脏科就诊时研究人群的特征相似(与对照组相比):0.91%的研究患者首次被诊断为PPCM患者,49%的患者在产后1个月内就诊。C反应蛋白(22 vs 08 mg/dl,p < 0.05)、TNF-α(9.6 vs 3.2 pg/dl,p < 0.01)和IL-6(73.19 ± 34.4 vs 31.52 ± 8.83 pg/dl,p < 0.005)显著异常,这些患者的左心室尺寸显著更高,左心室舒张末期内径(LV EDD)(61.6 ± 7.1 vs 46 ± 9 mm,p < 0.004),左心室收缩末期内径(LV ESD)(53.1 ± 7 vs 32 ± 8,p < 0.005),且超声心动图左心室射血分数(LVEF)显著更低(25.9 ± 8.2 vs 55 ± 12,p < 0.001),并与纽约心脏协会心功能分级(NYHA FC)和死亡密切相关。6个月时LVEF从25.9 ± 8.2%提高到42.9 + 13. %(p < 0.0001)。完成6个月标准治疗的患者心率、左心室尺寸和NYHA FC显著降低(p < 0.001)。然而,仅11名(35%)患者的LVEF恢复正常(>50%)。7名患者在诊断后6个月内死亡,8名患者失访。
PPCM患者的血浆炎症标志物显著升高,且与就诊时左心室尺寸增加和射血分数降低相关。基线CRP、IL-6、TNF-α和更高的NYHA FC是死亡的唯一预测因素。这些结果提示炎症可能参与PPCM的发病机制及其并发症和死亡预测。