Treatment with pentoxifylline was an independent predictor of favorable outcome with better LVEF, NYHA class, and survival. immunosuppressive therapy, they are currently not widely utilized.33, 35 The role of IVIG in PPCM was evaluated in a retrospective study of six women treated with IVIG and 11 controls treated conventionally.36 After a 6-month follow-up, the absolute increase in LVEF was greater in those treated with IVIG compared to controls (26% vs. 13%). However, the IMAC trial (Controlled Trial of Intravenous Immune Globulin in Recent-Onset Dilated Cardiomyopathy) showed that despite the potential therapeutic efficacy suggested by previous uncontrolled studies, immune globulin treatment of adult patients with recent-onset cardiomyopathy in this placebo-controlled trial did not affect improvements in LVEF or functional capacity during follow-up.36 This treatment strategy is based on an experimental observation of preventing PPCM in mice via prolactin blockade with bromocriptine.11 In a randomized open-label study performed in South Africa, 20 women with newly diagnosed PPCM were randomly assigned to receive NKP-1339 either standard care plus bromocriptine or standard care alone.37 The 10 women receiving bromocriptine demonstrated significantly greater improvement in LVEF compared to the 10 women receiving standard care only (27% to 58% vs. 27% to 36%). One patient in the bromocriptine group died compared to four in the standard care group. Fewer patients in the bromocriptine group reached the composite endpoint of death, NYHA functional class III or IV heart failure, or LVEF 35% at 6 months as compared to patients in the standard care group (1 vs. 8). The generalizability of these results is unclear given the small sample size, the higher than expected mortality rate in the standard care group, and differences in PPCM characteristics in patients in Africa as compared to those elsewhere. Further studies aimed at clearly establishing the efficacy and safety of bromocriptine are needed before it can be recommended for the treatment of PPCM. In a single center study involving 59 patients with PPCM, Sliwa et al. sought to evaluate the effects of pentoxifylline, a drug known to inhibit the production of TNF-, on clinical status, LV function, and circulating plasma levels of TNF-.16 One group was treated with diuretics, digoxin, enalapril, and carvedilol, and the other group received pentoxifylline 400 mg three times daily in addition to the previous therapy. Treatment with pentoxifylline was an independent predictor of favorable outcome with better LVEF, NYHA class, and survival. The promising Rabbit Polyclonal to KITH_VZV7 role of pentoxifylline remains experimental until it is validated by a larger scale, NKP-1339 placebo-controlled, NKP-1339 randomized clinical trial.16 Advanced Care and Device Therapy Decisions about both the necessity and timing of CRT or ICD implantation in PPCM patients are extremely difficult and require careful consideration of the risks and benefits and the natural history of PPCM. However, if a patient has persistently depressed LV dysfunction 6 months following presentation despite optimal medical therapy, implantation of an ICD is advised. CRT should be considered if the patient has NYHA class III or IV symptoms and a QRS 120 msec. For patients who are dependent on inotropes or intra-aortic balloon pump despite optimal medical therapy, implantation of a mechanical assist device or cardiac transplantation may be considered.22, 38 Prognosis Factors associated with favorable prognosis include small LV diastolic dimension ( 5.5C6.0 cm) and elevated systolic function (LVEF 30C35% and fractional shortening 20%) at the time of diagnosis,39, 40 absence of troponin elevation,41 absence of LV thrombus,29 and non-African American ethnicity.42 Recent multivariate analysis by Goland et al. in 187 patients with PPCM found LVEF 30% and LV end-diastolic dimension 55 mm to be significantly related to LV recovery, suggesting a relationship between the degree of initial myocardial insult and recovery.42 These parameters, however, have limited sensitivity in predicting recovery in individual patients. Despite the strong association between LVEF at time of diagnosis and rate of recovery, 70% of patients in group I (LVEF 10C19%) and 87% of patients in group II (LVEF 20C29%).