Bromocriptine-Induced Coronary Spasm Caused Acute Coronary Syndrome, Which Triggered Its Own Clinical Twin – Takotsubo Syndrome

Abstract

Bromocriptine-induced coronary spasm (BICS) causing myocardial infarction has been reported. Association between BICS and Takotsubo syndrome (TS) has not been described. We report on a 37-year-old woman presenting with a clinical picture of acute coronary syndrome 1 day after initiation of treatment with bromocriptine for ablactation 3 weeks after a full-term spontaneous vaginal delivery. Coronary angiography showed diffuse narrowing of a large diagonal branch. Left ventriculography showed widespread hypokinesia extending beyond the diagonal branch supply region. There was a slight elevation of myocardial infarction biomarkers that was disproportional to the degree of left ventricular dysfunction. Follow-up coronary angiography, intravascular ultrasound and left ventriculography showed normal coronary arteries including the diagonal branch and complete normalization of the left ventricular function. Cardiac magnetic resonance examination showed no signs of late myocardial gadolinium enhancement. The clinical picture and course of the disease was consistent with TS. Consequently, we describe for the first time a case of TS triggered by myocardial ischemia caused by BICS. Furthermore, our case and sufficient supporting data from the literature demonstrate that acute coronary syndrome is an important and frequent but up till now missed trigger factor for TS.

Peripartum Cardiomyopathy Presenting with Predominant Left Ventricular Diastolic Dysfunction: Efficacy of Bromocriptine

“…A recent study showed that breastfeeding—a major stimulus for the production of prolactin—was significantly associated with recovery of LV systolic function [22]. Cases where bromocriptine did not lead to benefit were also reported [23]. Caution is therefore needed in drawing conclusions about the effectiveness of bromocriptine in patients with PPCM.…”

“…Caution is therefore needed in drawing conclusions about the effectiveness of bromocriptine in patients with PPCM. Moreover, the safety of bromocriptine has been recently questioned, as cases of complications including myocardial infarction and stroke have been observed [23, 24]. …”

Post-ischemic myocardial stunning was the starting point of takotsubo syndrome: Restitution is justified after falling down on

“…Contraction band necrosis and vacuolization are also constant histopathological findings in TS [13]. Consequently, The LVWMA in PIMS and TS have similar clinical presentation and course, ECG, cardiac image, scintigraphic, and histopathologic findings [8]. Sato and Dote introduced the term "tsubo" or "takotsubo" in 1990 and 1991 [14,15] to describe the silhouette of the left ventricle during systole in 5 patients with findings of suggestive of acute myocardial infarction and no obstructive coronary artery disease.…”

“…In my opinion, PIMS has all the features of TS and it is a form of TS triggered by a coronary ischemic insult. The evidence for this suggestion is described in details elsewhere [5,7,8] and will be briefed here as follows: TS has an identical clinical presentation to that of ACS, which triggers PIMS. The development of evolutionary giant T-wave inversions and prolongation of QTc is a typical finding in some of the cases in both PIMS and TS.…”

Acute coronary syndrome or takotsubo syndrome: Most probably both of them, the first has triggered the second

“…Contraction band necrosis and vacuolization are also constant histopathological findings in TS [10]. Consequently, the LVWMA in PIMS and TS has similar clinical presentation and course, ECG, cardiac image, scintigraphic, and histopathologic findings [11]. Interestingly, Sato and Dote, when they first introduced the term takotsubo in 1990 and 1991, described the condition as myocardial stunning due to multi-vessel coronary spasm [3].…”