More study still needed on the use of bromocriptine in the treatment of peripartum cardiomyopathy

This commentary refers to ‘Bromocriptine for the treatment of peripartum cardiomyopathy: a multicentre randomized study’, by D. Hilfiker-Kleiner et al., 2017, on page 2671. 

A critical unanswered question in the treatment of peripartum cardiomyopathy (PPCM) regards the use of bromocriptine in addition to the already demonstrated effectiveness of ‘Guideline’ therapy for pregnancy-associated heart failure. Is bromocriptine safe to use in the peripartum time period? Does its addition significantly add to effectiveness of outcome?

The report of Hilfiker-Kleiner et al.,¹ has no non-use control group, leaving many unanswered questions. Earlier European studies with non-use of bromocriptine showed no statistically significant difference in outcomes compared to those who did use bromocriptine.²

Even with Hilfiker-Kleiner et al.’s,¹ use of anticoagulation in the treatment of all subjects receiving bromocriptine, ∼10% of one of their treatment groups experienced a major adverse event, with embolization or arterial occlusion. Numerous earlier reports of this type of vascular complication in users of bromocriptine led many physicians to stop using it in the peripartum setting.³ There were no thrombo-embolic events identified in the 99 IPAC subjects who did not use bromocriptine.⁴

Hilfiker-Kleiner et al.’s¹ comparison of outcomes with those of the IPAC report⁴ from North America limited comparisons to a subgroup (n = 27) of IPAC subjects diagnosed with a left ventricular ejection fraction (LVEF) of < 0.30; but fewer than 2/3 (37/57 or 64.9%) of European PPCM subjects had an LVEF < 0.30 at diagnosis.

As Hilfiker-Kleiner et al.,¹ pointed out, any comparisons had to be interpreted with caution since only 2% (1/63) of their subjects were of African heritage, while 30% (30/100) of the IPAC subjects were of African heritage.⁴ Reasons for poorer outcomes all over the world for PPCM subjects of African heritage are still being explored.

Evidence thus far is not convincing that bromocriptine actually adds effectiveness; but it does add a risk for serious adverse events.

Conflict of interest: none declared.

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