Screening for valve disease in patients with hyperprolactinaemia disorders prescribed cabergoline: a service evaluation and literature review

Abstract

Objectives:The indication for screening for valvular heart disease in patients taking cabergoline is based on evidence from patients with Parkinson's disease on high-dose medication. However, current patients take much lower doses for indications such as hyperprolactinaemia disorders. Contemporary guidelines for echocardiogram monitoring in patients taking cabergoline are conflicting. This study aimed to review current clinical practice in our area regarding echocardiographic screening and to review the literature examining the evidence of valvular heart disease in patients taking lower dose cabergoline. Methods: This was a retrospective study of all patients with hyperprolactinaemia disorders prescribed cabergoline in a single UK NHS health board between January 2014 and July 2015. The proportion of patients receiving baseline and follow-up echocardiograms was recorded. A review of the published literature was carried out using the databases EMBASE and Medline to examine the current evidence for the effect cabergoline has on cardiac valves in patients treated for hyperprolactinaemia disorders. Results: The mean age was 51.7 ± 16.5 years with a 64.4% female predominance. The mean duration of therapy was 5.9 years ± 4.1 years. Of the total cohort (n = 45), two (4.4%) patients had an initial baseline echocardiogram and five (13.2%) had follow-up echocardiograms every 24 months. Of the 25 articles identified, 12 showed no clinically significant evidence of valvular dysfunction in the cabergoline group groups. Of the remaining 13 articles, evidence for valvular changes was confined to high cumulative dose cabergoline patients and there was only one confirmed case of 'cabergoline associated valvulopathy' described. Conclusions: Clinically significant valvular dysfunction is uncommon and generally only reported in high cumulative dose treatment groups. We propose that clearer national guidelines are required and that echocardiogram screening be reserved for patients who are high risk, are taking a high weekly dose (⩾2 mg cabergoline weekly) or high cumulative dose.

Clinical, Hormonal, and Neuroradiological Characteristics and Therapeutic Outcomes of Prolactinomas in Children and Adolescents at a Single Center

“…Primary treatment for prolactinoma has recently changed from BRC to CAB, which has fewer side effects (such as GI issues and orthostatic hypotension) and greater therapeutic effect. However, risk of cardiac valve disease should be considered and regular echocardiography is required for patients who are taking a weekly dose of more than 2 mg CAB or high cumulative dose (41,42). Five of our patients (patients 7, 14, 15, 18, and 19) who recently performed echocardiography had no valvular abnormalities.…”

The Third Case of Cabergoline-Associated Valvulopathy: The Value of Routine Cardiovascular Examination for Screening

“…A recent community study from the United Kingdom demonstrated that very few patients with hyperprolactinemia had undergone baseline echocardiography (2 of 45), and only 5 of the 45 patients had undergone serial echocardiograms 2 years apart [ 3 ]. Even for those with Parkinson disease, a study showed that very few patients had had serial echocardiograms [ 14 ].…”

“…Since then, three further reported studies have not shown an increased prevalence of cabergoline-associated valvulopathy (CAV): now totaling 2000 cases of prolactinoma studied [ 2–4 ]. Studies of serial echocardiograms in patients with prolactinoma have not shown new cases of CAV [ 2 , 5 , 6 ]; however, in reality, few patients are undergoing serial echocardiograms [ 3 ].…”

Hyperprolactinaemia

“…High dose DA (as offered in Parkinson's syndrome) increases the risk of cardiac valvulopathy [95] but the risk of clinically significant valvulopathy in patients with prolactinoma is still not clearly established [96]. Most studies on prolactinoma patients do not show an elevated risk [97][98][99] but, given the uncertainty around the risk of valvulopathy in this setting, current guidelines recommend screening echocardiography prior to initiating DA, and thereafter every five years for patients taking cabergoline less than 2 mg per week or annually for those on more than 2 mg per week [100].…”