Indication for bromocriptine in peripartum cardiomyopathy

Abstract

We read with great interest the case report of Habedank et al.1 We would like to bring to your attention the fact that the authors overstate the efficacy of bromocriptine in their case report, and prematurely conclude with the indication of bromocriptine in the situation of peripartum cardiomyopathy. The authors report the case of a young patient presenting with acute heart failure within days following delivery of healthy twins. The clinical description along with the left ventricular dysfunction assessed through both echocardiography and cardiac MRI are clearly in favour of peripartum cardiomyopathy. Following the improvement in left ventricular ejection fraction assessed by MRI, from 15% after delivery to 60% two months later, the authors claim the efficacy of bromocriptine, prescribed for 6 weeks after delivery. However, bromocriptine was prescribed with the usual combination of a beta-blocker and ACE inhibitor. Even though low ejection fraction and left ventricular dilation at the acute phase of heart failure are pejorative for short-term left ventricular function recovery, it has been clearly demonstrated that such improvement can occur in some patients. We and others have reported cases of patients with initially very low ejection fraction and ventricular dilatation, who recovered normal cardiac function under beta-blocker and ACE inhibitor combination.2,3 The reasons underlying this left ventricular alteration after the acute phase remain unexplained. The hypothesis of potential treatment of patients with bromocriptine has recently been proposed by Hilfiker-Kleiner et al.,4 and is currently under clinical evaluation. Until the results of randomized trials are reported, this option should not be used routinely, and cautionary issues have already been raised.5 Even though we obviously cannot say that bromocriptine did not improve cardiac function in the case reported by Hadebank et al., the contrary is also true: unless the authors can show that the improvement was not related to usual beta-blocker and ACE-inhibitor treatment, their conclusion should be more balanced.