What is the role of bromocriptine in the management of peripartum cardiomyopathy?

Role of Bromocriptine in Peripartum Cardiomyopathy Management

Bromocriptine should be added to standard heart failure therapy in all patients with newly diagnosed peripartum cardiomyopathy (PPCM) as it significantly improves left ventricular recovery by interrupting the pathological prolactin cascade. 1

Pathophysiological Rationale

Bromocriptine's effectiveness in PPCM is based on a well-established pathophysiological mechanism:

• PPCM involves an oxidative stress-cathepsin D-16 kDa prolactin cascade that leads to:

  • Endothelial cell apoptosis
  • Impaired cardiomyocyte function
  • Vasoconstriction
  • Disruption of capillary structures 2, 1

• Bromocriptine, a dopamine D2 receptor agonist, suppresses prolactin production, thereby interrupting this pathological cascade 2, 1

Treatment Protocol

The recommended bromocriptine regimen is:

1. 2.5 mg twice daily for 2 weeks
2. Followed by 2.5 mg daily for 4 weeks 1

Important: Bromocriptine is an adjunct to, not a replacement for, standard heart failure therapy, which should include:

• Beta-blockers
• ACE inhibitors/ARBs (postpartum only)
• Diuretics (if needed for congestion)
• Hydralazine/nitrates (particularly during pregnancy) 1

Efficacy Evidence

Recent evidence strongly supports bromocriptine use:

• Meta-analysis (2025) showed bromocriptine is associated with:

  • Greater LVEF improvement (mean difference: 10.03%, 95% CI 3.88% to 16.17%)
  • Higher post-treatment LVEF (mean difference: 8.50%, 95% CI 3.39% to 13.61%) 3

• The EORP PPCM registry (2025) demonstrated:

  • Reduced composite endpoint of death, hospital readmission, or persistent severe LV dysfunction at 6 months (22% vs 33%)
  • Adjusted odds ratio of 0.47 (95% CI 0.31-0.70) for adverse maternal outcomes 4

• BRO-HF retrospective cohort study (2019) found:

  • Better mid-term LVEF recovery (from 23% to 55% at 6 months with bromocriptine vs 30% to 45% with standard therapy alone)
  • Independent association with greater LV functional recovery in adjusted analyses 5

Safety Considerations

Mandatory Anticoagulation

• All PPCM patients with low LVEF receiving bromocriptine must receive anticoagulation to prevent thromboembolic complications 1
• The EORP PPCM registry showed similar thromboembolic event rates between bromocriptine-treated and standard care groups (6.0% vs 5.6%) when appropriate anticoagulation was used 4

Monitoring Requirements

• Monitor for potential side effects:
  • Orthostatic hypotension
  • Mood changes 1

Breastfeeding Considerations

• Bromocriptine suppresses lactation, so mothers will be unable to breastfeed
• Studies have shown normal growth and survival of infants whose mothers received bromocriptine 6

Timing of Initiation

• Earlier initiation of bromocriptine is associated with better outcomes
• Treatment should not be delayed
• Consider immediate postpartum initiation in antepartum PPCM patients 1

Caveats and Pitfalls

1. Do not delay standard heart failure therapy while initiating bromocriptine
2. Never initiate bromocriptine without anticoagulation in patients with reduced LVEF
3. Do not rush to device therapy (e.g., ICD, LVAD) given the high rates of improvement with bromocriptine treatment 1
4. Greatest benefit appears to be in patients with more severe LV dysfunction (LVEF <30%) 3

Bromocriptine represents a pathophysiology-based, disease-specific treatment for PPCM that has demonstrated significant benefits for left ventricular recovery when added to standard heart failure therapy.