Mitral valve disease associated with long-term ergotamine use

Role of serotoninergic pathways in drug-induced valvular heart disease and diagnostic features by echocardiography

Serotonin plays a significant role in the development of carcinoid heart disease, which primarily leads to fibrosis and contraction of right-sided heart valves. Recently, strong evidence has emerged that the use of specific drug classes, such as ergot alkaloids (for migraine headaches), 5-hydroxytryptamine (5-HT or serotonin) uptake regulators or inhibitors (for weight reduction), and ergot-derived dopamine agonists (for Parkinson's disease), can result in left-sided heart valve damage that resembles carcinoid heart disease. Recent studies have suggested that both right-sided and left-sided drug-induced heart valve disease involves increased serotoninergic activity and in particular activation of the 5-HT receptors, including the 5-HT2B receptor subtype, which mediate many of the central and peripheral functions of serotonin. G-proteins that inhibit adenylate cyclase activity mediate the activity of the 5-HT2B receptor subunit, which is widely expressed in a variety of tissues, including liver, lung, heart, and coronary and pulmonary arteries; it has also been reported in embryonic mouse heart, particularly on mouse heart valve leaflets. In this review, the authors discuss the salient features of serotoninergic manifestations of both carcinoid heart disease and drug-induced cardiac valvulopathy, with an emphasis on echocardiographic diagnosis.

Valvulopathies sous pergolide : revue critique de la littérature et conduite à tenir en pratique

INTRODUCTION

Pergolide is a widely used antiparkinsonian dopamine agonist. Following occasional case reports, two studies recently suggested potentially frequent and severe valvular disease associated with pergolide intake.

STATE OF ART

Although there is now strong evidence to consider that pergolide may induce valvulopathy, incidence, severity, and risk factors for this adverse effect remain to be clarified. Valvular disease associated with pergolide consists in fibrosis and resembles conditions described in carcinoid carcinoma and in patients taking fenfluramine therapy. The mechanisms leading to valvular fibrosis are unknown but involvement of 5-HT(2B) receptors, especially expressed in valvular fibroblasts, is suspected.

PERSPECTIVES AND CONCLUSIONS

Following the recommendations of the Agence Française de Sécurité Sanitaire des Produits de Santé, we describe a clinical practice attitude for pergolide therapy in Parkinson's disease.

Fibrotic valvular heart disease subsequent to bromocriptine treatment

Ergot alkaloids, such as ergotamine, have been associated with numerous vascular complications and with valvular heart disease. The authors describe a man who developed fibrosis of three heart valves during a 5-year treatment with bromocriptine for Parkinson disease. There were no other plausible causes. To our knowledge, such a side effect has never been described with this drug.

Ergotamine/caffeine treatment of orthostatic hypotension in parkinsonism with autonomic failure

Eight patients with parkinsonism who developed severe orthostatic hypotension, were treated with oral ergotamine/caffeine. Significant long-term improvement in standing systolic blood pressure and symptoms of syncope and light-headedness were observed in four of these patients. One patient in whom the drug was effective discontinued it because of nausea. Another lost benefit after 2 weeks of successful therapy. Significant supine systolic hypertension occurred in only one patient, which was easily managed by nifedipine given at night. Symptoms or signs of ergotism were not observed. Oral ergotamine/caffeine should be considered as a cost-effective treatment for refractory orthostatic hypotension in carefully selected patients with parkinsonism. Copyright 1998 Lippincott Williams & Wilkins