Bromocriptine in Peripartum Cardiomyopathy: A Meta-Analysis with Trial Sequential Analysis

Bromocriptine has been proposed as a disease-modifying therapy for peripartum cardiomyopathy (PPCM). The long-term outcomes of bromocriptine use remain uncertain. We conducted a systematic review, meta-analysis and trial sequential analysis (TSA) to assess the long-term efficacy and safety of bromocriptine in combination with standard care versus standard care alone in patients with PPCM. We systematically searched PubMed, Embase and Cochrane up until March 2025 for published studies comparing bromocriptine plus standard care with standard care alone in patients with PPCM. The outcomes included changes in left ventricular (LV) ejection fraction, LV end-systolic and end-diastolic dimensions, major adverse cardiovascular events (MACE), all-cause mortality and rehospitalization. We computed mean differences (MDs) for continuous outcomes and odds ratios (ORs) for binary endpoints with 95% confidence intervals (CIs). We used TSA to assess the conclusiveness of the available evidence. A total of 12 studies 2 randomized controlled trials (RCTs) and 10 observational studies and 1765 patients (age range 29-33.8 years) were included, of whom 474 (26.9%) received bromocriptine with standard care and 1291 (73.1%) received standard care alone. Compared with standard care alone, bromocriptine with standard care was associated with a significant improvement in LV ejection fraction (MD 9.98%; 95% CI: 2.86 to 17.10; P < 0.001), LV end-diastolic diameter (MD -2.51 cm; 95% CI: -4.23 to -0.79; P = 0.004), and LV end-systolic diameter (MD -5.61 cm; 95% CI: -10.03 to -1.18; P = 0.010). The proportion of patients with improved LV function was higher in those who received bromocriptine with standard care than in those who received standard care alone (OR 0.35; 95% CI: 0.16 to 0.75; P = 0.007). There were no significant differences between groups regarding the incidence of MACE, all-cause mortality or heart failure rehospitalization. The TSA showed that LV ejection fraction and diastolic dimension reached the required information size (RIS); however, only LV ejection fraction crossed the monitoring boundary before the full sample size was achieved. In this meta-analysis with TSA, the use of bromocriptine with standard care was associated with improved LV function and remodelling in patients with PPCM compared with standard care alone, with a similar effect on mortality and re-hospitalization. TSA indicated that current evidence is promising, but larger and adequately powered randomized trials are needed to confirm bromocriptine's cardioprotective effects.