Practice Update: Cardiology

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Bromocriptine
Effective for
the Treatment
of Peripartum
Cardiomyopathy
European Heart Journal
Take-home message
• This prospective, multicenter study (N = 63) evaluated
the effectiveness of bromocriptine for the treatment of
left ventricular (LV) dysfunction in women with peripartum
cardiomyopathy. The study compared outcomes in patients
treated either for 1 week or 8 weeks with bromocriptine
with outcomes in control cohorts who were not treated
with bromocriptine. The results showed that 1- or 8-week
bromocriptine treatment was associated with a significant
improvement in LVEF 6 months after the treatment.
• Although bromocriptine treatment for 1 week and for 8
weeks was comparable in terms of LVEF improvement,
8-week treatment offered a better prospect of full recovery
than 1-week treatment (68% vs 52%, respectively).
Abstract
AIMS An anti-angiogenic cleaved prolactin fragment is considered causal
for peripartum cardiomyopathy (PPCM). Experimental and first clinical
observations suggested beneficial effects of the prolactin release inhib-
itor bromocriptine in PPCM.
METHODS AND RESULTS In this multicentre trial, 63 PPCM patients with left
ventricular ejection fraction (LVEF) ≤35% were randomly assigned to
short-term (1W: bromocriptine, 2.5mg, 7 days) or long-term bromocrip-
tine treatment (8W: 5mg for 2weeks followed by 2.5mg for 6weeks) in
addition to standard heart failure therapy. Primary end point was LVEF
change (delta) from baseline to 6months assessed by magnetic resonance
imaging. Bromocriptine was well tolerated. Left ventricular ejection frac-
tion increased from 28± 10% to 49± 12% with a delta-LVEF of +21 ± 11% in
the 1W-group, and from 27 ± 10% to 51 ± 10% with a delta-LVEF of +24± 11%
in the 8W-group (delta-LVEF: P =0.381). Full-recovery (LVEF ≥ 50%) was
present in 52% of the 1W- and in 68% of the 8W-group with no differences
in secondary end points between both groups (hospitalizations for heart
failure: 1W: 9.7% vs. 8W: 6.5%, P=0.651). The risk within the 8W-group to
fail full-recovery after 6months tended to be lower. No patient in the study
needed heart transplantation, LV assist device or died.
CONCLUSION Bromocriptine treatment was associated with high rate of full
LV-recovery and low morbidity and mortality in PPCM patients compared
with other PPCM cohorts not treated with bromocriptine. No significant
differences were observed between 1W and 8W treatment suggesting
that 1-week addition of bromocriptine to standard heart failure treatment
is already beneficial with a trend for better full-recovery in the 8W group.
Bromocriptine for the treatment of peripartum cardiomyopathy: a multi-
centre randomized study. Eur Heart J 2017 Jul 27;[EPub Ahead of Print],
D Hilfiker-Kleiner, A Haghikia, D Berliner, et al.
Antiplatelet Regimen
for PatientsWith
Breakthrough
StrokesWhile on
Aspirin
Stroke; A Journal of Cerebral Circulation
Take-home message
• In this meta-analysis, researchers sought to identify ideal
management of patients who have an ischemic stroke
or transient ischemic attack (TIA) while taking aspirin. A
total of 5 studies including 8723 patients were included
in the analysis. Compared with continuing aspirin alone,
adding or switching to another antiplatelet drug after a
stroke or TIA was associated with a significantly lower
risk for major adverse cardiovascular events (HR, 0.68)
and recurrent stroke (HR, 0.70). This benefit was most
consistent when the new regimen was initiated in the
first few days after the initial event.
• The results of this study support the practice of switching
or adding an antiplatelet after a stroke or TIA occurs in
a patient already taking aspirin. Importantly, this change
is most effective when it occurs within the first few days
after the ischemic event.
Abstract
BACKGROUND AND PURPOSE Optimal antiplatelet therapy after an
ischemic stroke or transient ischemic attack while on aspirin is uncer-
tain. We, therefore, conducted a systematic review and meta-analysis.
METHODS We searched PubMed (1966 to August 2016) and bibliog-
raphies of relevant published original studies to identify randomized
trials and cohort studies reporting patients who were on aspirin at
the time of an index ischemic stroke or transient ischemic attack and
reported hazard ratio for major adverse cardiovascular events or
recurrent stroke associated with a switch to or addition of another
antiplatelet agent versus maintaining aspirin monotherapy. Estimates
were combined using a random effects model.
RESULTS Five studies with 8723 patients with ischemic stroke or tran-
sient ischemic attack were identified. Clopidogrel was used in 4
cohorts, and ticagrelor was used in 1 cohort. Pooling results showed
that addition of or a switch to another antiplatelet agent, versus aspi-
rin monotherapy, was associated with reduced risks of major adverse
cardiovascular events (hazard ratio, 0.68; 95% confidence interval,
0.54-0.85) and recurrent stroke (hazard ratio, 0.70; 95% confidence
interval, 0.54-0.92). Each of the strategies of addition of and switching
another antiplatelet agent showed benefit versus continued aspirin
monotherapy, and studies with regimen initiation in the first days after
index event showed more homogenous evidence of benefit.
CONCLUSIONS Among patients who experience an ischemic stroke or
transient ischemic attack while on aspirin monotherapy, the addition
of or a switch to another antiplatelet agent, especially in the first days
after index event, is associated with fewer future vascular events,
including stroke.
Antiplatelet regimen for patients with breakthrough strokes while
on aspirin: a systematic review and meta-analysis. Stroke 2017 Jul
12;[EPub Ahead of Print], M Lee, JL Saver, KS Hong, et al.
GENERAL CARDIOLOGY 22
PRACTICEUPDATE CARDIOLOGY