**5.5 Angiogenic imbalance and balance**

Human and animal studies suggest that PPCM is caused by systemic angiogenic imbalance. Animals that lack cardiac PGC-1α, a regulator of proangiogenic factors such as VEGF, develop severe PPCM. These data may also explain why preeclampsia and multiple gestations are risk factors for PPCM. During late gestation, the human placenta secretes VEGF inhibitors such as soluble fms-like tyrosine kinase 1 (sFlt1), which damages the vasculature, with higher levels seen with multiple gestations or preeclampsia. Preeclampsia and multiple gestations are risk factors for PPCM as in these patients subclinical cardiac dysfunction correlates with sFlt1 levels [18].
