CORRESPONDENCE: LETTER TO THE EDITOR
Reply
Denise Hilfiker-Kleiner, PhD* and
Helmut Drexler, MD
* Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg Strasse 1, 30625 Hannover, Germany (Email: hilfiker.denise{at}mh-hannover.de).
We have not made the claim that our 2 cases would establish bromocriptine as a treatment for peripartum cardiomyopathy (PPCM), and 2 clinical cases never prove a novel concept. We stated this clearly and mentioned that the efficacy of bromocriptine in treating PPCM patients has to be evaluated in a controlled randomized clinical trial (1). Thus, we agree with Dr. Fett's point that these 2 case reports are no proof for a beneficial effect of bromocriptine in PPCM, even though meanwhile we have made similar beneficial observations in 5 additional patients, applying the same protocol.
Concerning the safety of bromocriptine, there are in fact several case reports on myocardial infarction in early post-partum women in association with taking bromocriptine (2). However, there is a naturally increased risk for thrombosis and myocardial infarction in post-partum women (3). The risk for spontaneous coronary artery dissection is also increased during pregnancy and in the post-partum period independently from bromocriptine (4). Thus, there are numerous reports on myocardial infarction in early post-partum women independent of bromocriptine (5,6). Left ventricular failure further increases the risk for thrombosis and infarction, and anticoagulation therapy is strongly encouraged for these reasons in PPCM patients. It should be noted that bromocriptine has been used for more than 20 years successfully and safely to stop lactation.
Dr. Fett raises the question of whether it is ethical in third world countries to stop lactation in a woman with severe heart failure, because this would increase the risk for the infant for infection and malnutrition. Nursing is considered as an additional stress factor for the mother's heart. In addition, standard medication to treat heart failure (angiotensin-converting enzyme-inhibitor, beta-blocker, and diuretic drugs) might be harmful for the infant. Therefore, we would like to ask in return whether it is ethical to expose women with severe heart failure due to PPCM and their infants in a third world country to a higher risk for death or disability because of nursing?
We should all aim to work together to find solutions and hopefully efficient ways to treat this deadly disease and help affected patients. Our goal is to establish as soon as possible whether bromocriptine is efficient and safe to treat PPCM. Professor Sliwa in South Africa has already started a controlled randomized trial, and we are planning a trial in Europe and the U.S. Dr. Fett would be in an ideal position in Haiti, with its high incidence of PPCM, to take action!
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1. Hilfiker-Kleiner D, Meyer GP, Schieffer E, et al. Recovery from postpartum cardiomyopathy in 2 patients by blocking prolactin release with bromocriptine J Am Coll Cardiol 2007;50:2354-2355.[Free Full Text]2. Hopp L, Weisse AB, Iffy L. Acute myocardial infarction in a healthy mother using bromocriptine for milk suppression Can J Cardiol 1996;12:415-418.[Web of Science][Medline] 3. James AH, Brancazio LR, Ortel TL. Thrombosis, thrombophilia, and thromboprophylaxis in pregnancy Clin Adv Hematol Oncol 2005;3:187-197.[Medline] 4. Goland S, Schwarz ER, Siegel RJ, Czer LS. Pregnancy-associated spontaneous coronary artery dissection Am J Obstet Gynecol 2007;197:e11-e13.[CrossRef][Web of Science][Medline] 5. Patti G, Nasso G, D'Ambrosio A, Manzoli A, Di Sciascio G. Myocardial infarction during pregnancy and postpartum: a review G Ital Cardiol 1999;29:333-338.[Medline] 6. Roth A, Elkayam U. Acute myocardial infarction associated with pregnancy Ann Intern Med 1996;125:751-762.[Abstract/Free Full Text]
Related Article
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Caution in the Use of Bromocriptine in Peripartum Cardiomyopathy
- James D. Fett
J. Am. Coll. Cardiol. 2008 51: 2083.
[Full Text]
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