From the Guidelines
Dihydroergotamine (DHE) is contraindicated in patients with a history of Coronary Artery Disease (CAD) due to its potential to cause coronary vasospasm and worsen myocardial ischemia. This is based on the evidence from the American Family Physician study 1, which lists CAD as a contraindication for DHE. The study highlights the risks of using DHE in patients with CAD, including coronary vasospasm, cardiac events, and myocardial infarction.
Key Points to Consider
- DHE is an ergot alkaloid that causes potent vasoconstriction, which can reduce blood flow to the coronary arteries and trigger coronary vasospasm in patients with pre-existing CAD.
- The use of DHE in patients with CAD can worsen myocardial ischemia or precipitate a heart attack.
- Other contraindications for DHE include peripheral vascular disease, uncontrolled hypertension, stroke, hemiplegic or basilar migraine, and concurrent use of potent CYP3A4 inhibitors or other vasoconstrictive medications.
- For patients with CAD who need migraine treatment, safer alternatives include non-steroidal anti-inflammatory drugs (NSAIDs), certain anticonvulsants, or CGRP antagonists, which should be selected in consultation with both a neurologist and cardiologist.
Important Considerations for Treatment
- Patients with CAD should avoid using DHE and instead opt for alternative treatments that are safer and more effective for their specific condition.
- The selection of alternative treatments should be based on the individual patient's needs and medical history, and should be made in consultation with a neurologist and cardiologist.
- It is essential to carefully evaluate the risks and benefits of any treatment option for patients with CAD, and to prioritize their safety and well-being above all else.
From the FDA Drug Label
Dihydroergotamine mesylate should not be used by patients with documented ischemic or vasospastic coronary artery disease (see CONTRAINDICATIONS) It is strongly recommended that dihydroergotamine mesylate not be given to patients in whom unrecognized coronary artery disease (CAD) is predicted by the presence of risk factors
Dihydroergotamine (DHE) is contraindicated in patients with a history of Coronary Artery Disease (CAD) 2.
From the Research
Dihydroergotamine (DHE) Contraindications
- DHE is contraindicated in patients with a history of cardiac disease and peripheral vascular disease due to its association with acute vasoconstriction mediated through the 5HT1B receptor 3
- The medication is also contraindicated in patients with ischemic heart disease or coronary vasospasm, similar to triptans 4
Cardiovascular Risk Factors
- Studies have evaluated the safety and efficacy of DHE in patients with cardiovascular risk factors, including those with atherosclerotic cardiovascular disease 10-year calculated risk scores 4
- One study found that repetitive intravenous DHE was safe in refractory chronic migraine patients with elevated cardiovascular risk, with no clinically significant electrocardiogram abnormalities or cardiovascular adverse events 4
Vasoconstrictive Effects
- DHE has been shown to induce vasoconstriction in various blood vessels, including coronary arteries, meningeal arteries, and saphenous veins 5
- However, the vasoconstrictive effects of DHE on diseased epicardial coronary arteries were found to be minimal in one study 6
Clinical Implications
- The use of DHE in patients with a history of Coronary Artery Disease (CAD) should be approached with caution, considering the potential risks of vasoconstriction and cardiovascular adverse events 3, 4
- Further studies are needed to fully understand the safety and efficacy of DHE in patients with CAD and other cardiovascular risk factors 4, 7