Practice Update: Cardiology

GENERAL CARDIOLOGY 22

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. www.practiceupdate.com/c/55835

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. www.practiceupdate.com/c/56373

PRACTICEUPDATE CARDIOLOGY