In peripartum cardiomyopathy plasminogen activator inhibitor-1 is a potential new biomarker with controversial roles

Cardiovasc Res. 2020 Sep 1;116(11):1875-1886. doi: 10.1093/cvr/cvz300.


Aims: Peripartum cardiomyopathy (PPCM) is a life-threatening heart disease occurring in previously heart-healthy women. A common pathomechanism in PPCM involves the angiostatic 16 kDa-prolactin (16 kDa-PRL) fragment, which via NF-κB-mediated up-regulation of microRNA-(miR)-146a induces vascular damage and heart failure. We analyse whether the plasminogen activator inhibitor-1 (PAI-1) is involved in the pathophysiology of PPCM.

Methods and results: In healthy age-matched postpartum women (PP-Ctrl, n = 53, left ventricular ejection fraction, LVEF > 55%), PAI-1 plasma levels were within the normal range (21 ± 10 ng/mL), but significantly elevated (64 ± 38 ng/mL, P < 0.01) in postpartum PPCM patients at baseline (BL, n = 64, mean LVEF: 23 ± 8%). At 6-month follow-up (n = 23), PAI-1 levels decreased (36 ± 14 ng/mL, P < 0.01 vs. BL) and LVEF (49 ± 11%) improved. Increased N-terminal pro-brain natriuretic peptide and Troponin T did not correlate with PAI-1. C-reactive protein, interleukin (IL)-6 and IL-1β did not differ between PPCM patients and PP-Ctrl. MiR-146a was 3.6-fold (P < 0.001) higher in BL-PPCM plasma compared with PP-Ctrl and correlated positively with PAI-1. In BL-PPCM serum, 16 kDa-PRL coprecipitated with PAI-1, which was associated with higher (P < 0.05) uPAR-mediated NF-κB activation in endothelial cells compared with PP-Ctrl serum. Cardiac biopsies and dermal fibroblasts from PPCM patients displayed higher PAI-1 mRNA levels (P < 0.05) than healthy controls. In PPCM mice (due to a cardiomyocyte-specific-knockout for STAT3, CKO), cardiac PAI-1 expression was higher than in postpartum wild-type controls, whereas a systemic PAI-1-knockout in CKO mice accelerated peripartum cardiac fibrosis, inflammation, heart failure, and mortality.

Conclusion: In PPCM patients, circulating and cardiac PAI-1 expression are up-regulated. While circulating PAI-1 may add 16 kDa-PRL to induce vascular impairment via the uPAR/NF-κB/miR-146a pathway, experimental data suggest that cardiac PAI-1 expression seems to protect the PPCM heart from fibrosis. Thus, measuring circulating PAI-1 and miR-146a, together with an uPAR/NF-κB-activity assay could be developed into a specific diagnostic marker assay for PPCM, but unrestricted reduction of PAI-1 for therapy may not be advised.

Keywords: Biomarker; Heart failure; PAI-1; Peripartum cardiomyopathy; miR-146a.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Animals
  • Biomarkers / blood
  • Cardiomyopathies / blood*
  • Cardiomyopathies / diagnostic imaging
  • Cardiomyopathies / physiopathology
  • Case-Control Studies
  • Disease Models, Animal
  • Female
  • Humans
  • Mice, Knockout
  • Myocytes, Cardiac / metabolism
  • Parity
  • Peripartum Period / blood*
  • Plasminogen Activator Inhibitor 1 / blood*
  • Plasminogen Activator Inhibitor 1 / genetics
  • Pregnancy
  • Prognosis
  • Puerperal Disorders / blood*
  • Puerperal Disorders / diagnostic imaging
  • Puerperal Disorders / physiopathology
  • Recovery of Function
  • STAT3 Transcription Factor / genetics
  • STAT3 Transcription Factor / metabolism
  • Stroke Volume
  • Time Factors
  • Up-Regulation
  • Ventricular Function, Left


  • Biomarkers
  • Plasminogen Activator Inhibitor 1
  • SERPINE1 protein, human
  • STAT3 Transcription Factor
  • Stat3 protein, mouse