No abstract

Myocarditis is an uncommon, potentially life-threatening disease that presents with a wide range of symptoms in children and adults. Viral infection is the most common cause of myocarditis in developed countries, but other etiologies include bacterial and protozoal infections, toxins, drug reactions, autoimmune diseases, giant cell myocarditis, and sarcoidosis. Acute injury leads to myocyte damage, which in turn activates the innate and humeral immune system, leading to severe inflammation. In most patients, the immune reaction is eventually down-regulated and the myocardium recovers. In select cases, however, persistent myocardial inflammation leads to ongoing myocyte damage and relentless symptomatic heart failure or even death. The diagnosis is usually made based on clinical presentation and noninvasive imaging findings. Most patients respond well to standard heart failure therapy, although in severe cases, mechanical circulatory support or heart transplantation is indicated. Prognosis in acute myocarditis is generally good except in patients with giant cell myocarditis. Persistent, chronic myocarditis usually has a progressive course but may respond to immunosuppression.

Background-Peripartum cardiomyopathy (PPCM) is a potentially life-threatening heart disease that occurs in previously healthy women. We identified prolactin, mainly its 16-kDa angiostatic and proapoptotic form, as a key factor in PPCM pathophysiology. Previous reports suggest that bromocriptine may have beneficial effects in women with acute onset of PPCM. Methods and Results-A prospective, single-center, randomized, open-label, proof-of-concept pilot study of women with newly diagnosed PPCM receiving standard care (PPCM-Std; nϭ10) versus standard care plus bromocriptine for 8 weeks (PPCM-Br, nϭ10) was conducted. Because mothers receiving bromocriptine could not breast-feed, the 6-month outcome of their children (nϭ21) was studied as a secondary end point. Blinded clinical, hemodynamic, and echocardiographic assessments were performed at baseline and 6 months after diagnosis. Cardiac magnetic resonance imaging was performed 4 to 6 weeks after diagnosis in PPCM-Br patients. There were no significant differences in baseline characteristics, including serum 16-kDa prolactin levels and cathepsin D activity, between the 2 study groups. PPCM-Br patients displayed greater recovery of left ventricular ejection fraction (27% to 58%; Pϭ0.012) compared with PPCM-Std patients (27% to 36%) at 6 months. One patient in the PPCM-Br group died compared with 4 patients in the PPCM-Std group. Significantly fewer PPCM-Br patients (nϭ1, 10%) experienced the composite end point of poor outcome defined as death, New York Heart Association functional class III/IV, or left ventricular ejection fraction Ͻ35% at 6 months compared with the PPCM-Std patients (nϭ8, 80%; Pϭ0.006). Cardiac magnetic resonance imaging revealed no intracavitary thrombi. Infants of mothers in both groups showed normal growth and survival. Conclusions-In this trial, the addition of bromocriptine to standard heart failure therapy appeared to improve left ventricular ejection fraction and a composite clinical outcome in women with acute severe PPCM, although the number of patients studied was small and the results cannot be considered definitive. Larger-scale multicenter and blinded studies are in progress to test this strategy more robustly. (Circulation. 2010;121:1465-1473.)Key Words: cardiomyopathy Ⅲ heart failure Ⅲ hormones Ⅲ parturition Ⅲ pregnancy P eripartum cardiomyopathy (PPCM) is characterized by new onset of heart failure between 1 month before and 5 months after delivery in previously healthy women. 1 The clinical presentation and management of PPCM and its outcome have been reviewed recently. 1,2 Only 23% to 54% of patients show recovery of cardiac function within 6 months. [3][4][5][6] Investigation of a large cohort of PPCM patients demonstrated that this condition is associated with a proinflammatory response, as evidenced by elevated plasma levels of tumor necrosis factor-␣, Fas-Apo-1, interleukin-6, and C-reactive protein (CRP). 5,7,8 Editorial see p 1463 Clinical Perspective on p 1473We recently reported that enhanced oxidative stress in a mou...