Pulmonary regurgitation medical therapy: Difference between revisions
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__NOTOC__ | __NOTOC__ | ||
{{Pulmonic regurgitation}} | {{Pulmonic regurgitation}} | ||
{{CMG}}{{AE}} {{AKI}}, {{AA}} | {{CMG}}{{AE}} {{AKI}}, {{AA}}, {{JA}} | ||
==Overview == | ==Overview == | ||
Treatment of pulmonic regurgitation may be divided into medical and surgical treatment. Medical management of pulmonic regurgitation may include use of diuretics in patients with RV dysfunction. ACE inhibitors and | Treatment of [[pulmonic regurgitation]] may be divided into medical and surgical treatment. Medical management of [[pulmonic regurgitation]] may include use of [[diuretics]] in patients with [[RV dysfunction]]. [[ACE inhibitors]] and [[beta blockers]] may be used to reverse neurohormonal activation and improve symptoms. [[Antibiotic]] [[prophylaxis]] may be indicated in certain conditions such as patients with [[cyanotic heart disease]], [[prosthetic heart valves]], [[rheumatic heart disease]], and patients previously having sustained [[bacterial endocarditis]]. Among [[patients]] with [[carcinoid syndrome|carcinoid heart disease]] [[subcutaneously]] administered [[octreotide]] in 2–4 divided doses (50–1500 μg/day) provides symptomatic and biochemical benefit. | ||
==Medical Therapy== | |||
*There are no specific medical measures for management of PR. | *There are no specific medical measures for the management of [[PR]]. | ||
*Diuretics are recommended in patients with RV dysfunction for maintenance of fluid balance. | *[[Diuretics]] are recommended in patients with [[RV dysfunction]] or [[PAH]] for maintenance of fluid balance.<ref>{{cite book | last = Fauci | first = Anthony | title = Harrison's principles of internal medicine | publisher = McGraw-Hill Medical | location = New York | year = 2008 | isbn = 978-0071466332 }}</ref> | ||
* | *Among [[patients]] with repaired [[Tetralogy of Fallot|tetralogy of fallot]], [[ACE inhibitor|ACE inhibitors]] or [[Beta blockers|beta-blockers]] are used to reverse the neuroharmonal activation and improve the symptoms.<ref name="pmid12093776">{{cite journal| author=Bolger AP, Sharma R, Li W, Leenarts M, Kalra PR, Kemp M et al.| title=Neurohormonal activation and the chronic heart failure syndrome in adults with congenital heart disease. | journal=Circulation | year= 2002 | volume= 106 | issue= 1 | pages= 92-9 | pmid=12093776 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12093776 }} </ref><ref name="pmid12354712">{{cite journal| author=Davos CH, Davlouros PA, Wensel R, Francis D, Davies LC, Kilner PJ et al.| title=Global impairment of cardiac autonomic nervous activity late after repair of tetralogy of Fallot. | journal=Circulation | year= 2002 | volume= 106 | issue= 12 Suppl 1 | pages= I69-75 | pmid=12354712 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12354712 }} </ref> | ||
'' | ===Anticoagulation=== | ||
*Administration of systemic [[anticoagulation]] has led to risk reduction of major [[thromboembolic]] events among [[patients]] with [[mechanical valves]]. The risks reduced from 23 per 100 patient-years to<ref name="pmid8313552">{{cite journal |vauthors=Cannegieter SC, Rosendaal FR, Briët E |title=Thromboembolic and bleeding complications in patients with mechanical heart valve prostheses |journal=Circulation |volume=89 |issue=2 |pages=635–41 |date=February 1994 |pmid=8313552 |doi=10.1161/01.cir.89.2.635 |url=}}</ref>: | |||
** 2.2 per 100 patient-years with [[Antiplatelet drug|antiplatelet therapy]] | |||
** 1 per 100 patient-years with [[warfarin]] | |||
*Among [[patients]] [[New york heart association functional classification|NYHA functional class]] I or II and a small prosthetic clot, short-term [[IV]] [[unfractionated heparin]] or continuous [[fibrinolytic therapy]] can be administered.<ref name="pmid18820172">{{cite journal |vauthors=Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O'Gara PT, O'Rourke RA, Otto CM, Shah PM, Shanewise JS |title=2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons |journal=Circulation |volume=118 |issue=15 |pages=e523–661 |date=October 2008 |pmid=18820172 |doi=10.1161/CIRCULATIONAHA.108.190748 |url=}}</ref> | |||
*The [[treatment]] of choice for obstructive [[thrombosis]] among [[critically ill]] [[patients]] without serious [[comorbidity]] is urgent [[valve]] replacement. (European Society of Cardiology guidelines)<ref name="pmid17259184">{{cite journal |vauthors=Vahanian A, Baumgartner H, Bax J, Butchart E, Dion R, Filippatos G, Flachskampf F, Hall R, Iung B, Kasprzak J, Nataf P, Tornos P, Torracca L, Wenink A |title=Guidelines on the management of valvular heart disease: The Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology |journal=Eur. Heart J. |volume=28 |issue=2 |pages=230–68 |date=January 2007 |pmid=17259184 |doi=10.1093/eurheartj/ehl428 |url=}}</ref> | |||
The American Heart Association Recommendations on Prevention of [[Bacterial Endocarditis]] indicate that antibiotic prophylaxis is not necessary for pulmonic regurgitation in those patients with otherwise structurally normal pulmonic valves, particularly if there is no [[diastolic murmur]]. It should be noted, though, that those patients with the following conditions may warrant antibiotic prophylaxis:<ref name="pmid15201262">{{cite journal| author=Seiler C| title=Management and follow up of prosthetic heart valves. | journal=Heart | year= 2004 | volume= 90 | issue= 7 | pages= 818-24 | pmid=15201262 | doi=10.1136/hrt.2003.025049 | pmc=1768319 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15201262 }} </ref> | ===Antiobiotic prophylaxis=== | ||
The [[American Heart Association]] Recommendations on Prevention of [[Bacterial Endocarditis]] indicate that [[antibiotic]] [[prophylaxis]] is not necessary for [[pulmonic regurgitation]] in those patients with otherwise structurally normal [[pulmonic valves]], particularly if there is no [[diastolic murmur]]. It should be noted, though, that those patients with the following conditions may warrant antibiotic prophylaxis:<ref name="pmid15201262">{{cite journal| author=Seiler C| title=Management and follow up of prosthetic heart valves. | journal=Heart | year= 2004 | volume= 90 | issue= 7 | pages= 818-24 | pmid=15201262 | doi=10.1136/hrt.2003.025049 | pmc=1768319 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15201262 }} </ref> | |||
#Complex [[cyanotic heart disease]] | #Complex [[cyanotic heart disease]] | ||
#[[Prosthetic heart valves]] | #[[Prosthetic heart valves]] | ||
#Patients with congenital heart disease and pulmonic regurgitation | #Patients with [[congenital heart disease]] and [[pulmonic regurgitation]] | ||
#Acquired pulmonic valve regurgitation as the result of [[rheumatic heart disease]] | #Acquired pulmonic valve regurgitation as the result of [[rheumatic heart disease]] | ||
#Patients with complex cyanotic heart disease | #Patients with complex [[cyanotic heart disease]] | ||
#In patients who have previously sustained [[bacterial endocarditis]] | #In patients who have previously sustained [[bacterial endocarditis]] | ||
*The [[antibiotic]] [[prophylaxis]] if required is reasonable within 6 months after the procedure.<ref name="pmid17446442">{{cite journal |vauthors=Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, Bolger A, Cabell CH, Takahashi M, Baltimore RS, Newburger JW, Strom BL, Tani LY, Gerber M, Bonow RO, Pallasch T, Shulman ST, Rowley AH, Burns JC, Ferrieri P, Gardner T, Goff D, Durack DT |title=Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group |journal=Circulation |volume=116 |issue=15 |pages=1736–54 |date=October 2007 |pmid=17446442 |doi=10.1161/CIRCULATIONAHA.106.183095 |url=}}</ref> | |||
*Among [[patients]] with severe acute [[PR]] due to the large duct (such as in neonatal [[Ebstein's anomaly]] or post balloon dilation of [[pulmonary stenosis]] or [[perforation]] of valvar [[pulmonary atresia]])<ref name="pmid16169376">{{cite journal |vauthors=Wald RM, Adatia I, Van Arsdell GS, Hornberger LK |title=Relation of limiting ductal patency to survival in neonatal Ebstein's anomaly |journal=Am. J. Cardiol. |volume=96 |issue=6 |pages=851–6 |date=September 2005 |pmid=16169376 |doi=10.1016/j.amjcard.2005.05.035 |url=}}</ref><ref name="pmid17569817">{{cite journal |vauthors=Chaturvedi RR, Redington AN |title=Pulmonary regurgitation in congenital heart disease |journal=Heart |volume=93 |issue=7 |pages=880–9 |date=July 2007 |pmid=17569817 |pmc=1994453 |doi=10.1136/hrt.2005.075234 |url=}}</ref>: | |||
** If [[TR]] accompanies the situation, a circular shunt may occur leading to poor systemic blood flow. The treatment involves stopping the [[prostaglandins]] and urgent duct ligation among unstable [[patients]]. | |||
**If [[tricuspid valve]] is competent, increasing [[ventilation]], [[oxygen]], and [[nitric oxide]] to cause [[pulmonary vasodilatation]] can reduce [[PR]]. | |||
===Heart failure therapy=== | |||
*General measures for the treatment of [[heart failure]] include<ref name="pmid15367531">{{cite journal |vauthors=Fox DJ, Khattar RS |title=Carcinoid heart disease: presentation, diagnosis, and management |journal=Heart |volume=90 |issue=10 |pages=1224–8 |date=October 2004 |pmid=15367531 |pmc=1768473 |doi=10.1136/hrt.2004.040329 |url=}}</ref>: | |||
**Diet: Salt and water restriction | |||
**Monitoring: Weight and fluid balance monitoring | |||
**Mobility: Mobility and [[compression stockings]] help prevent the development of [[DVT|deep venous thrombosis]] and leg [[edema]]. | |||
**[[Right heart failure]]: A combination of [[loop diuretics]] and [[digoxin]] (may help with [[RV|right ventricular]] contractility). Often, loop diuretics alone are enough to achieve sufficient fluid loss, but if additional diuresis is required, the judicious coadministration of a [[Thiazide diuretic]] may be administered with loop diuretics to achieve optimal fluid balance. | |||
*To read more about the medical therapy utilized in heart failure, [[Congestive heart failure#Treatment|click here]]. | |||
===[[Carcinoid syndrome|Carcinoid heart disease]]<ref name="pmid15367531">{{cite journal |vauthors=Fox DJ, Khattar RS |title=Carcinoid heart disease: presentation, diagnosis, and management |journal=Heart |volume=90 |issue=10 |pages=1224–8 |date=October 2004 |pmid=15367531 |pmc=1768473 |doi=10.1136/hrt.2004.040329 |url=}}</ref><ref name="pmid9156122">{{cite journal |vauthors=Janmohamed S, Bloom SR |title=Carcinoid tumours |journal=Postgrad Med J |volume=73 |issue=858 |pages=207–14 |date=April 1997 |pmid=9156122 |pmc=2431281 |doi=10.1136/pgmj.73.858.207 |url=}}</ref>=== | |||
[[Subcutaneously]] administered [[octreotide]] in 2–4 divided doses (50–1500 μg/day) provides symptomatic and [[biochemical tests|biochemical]] benefit. [[Octreotide]] ([[somatostatin analog]]) binds to [[somatostatin receptors]], and reduces the [[vasoactive peptides]] that provoke [[carcinoid syndrome]]. Concomitant monitoring of [[BSL]] and [[blood glucose levels]] is required. [[Lanreotide]] (BIM23014, [[angiopeptin]] and [[somatuline]]) is a newer [[somatostatin analog]], has an advantage of less frequent administrations, and can be used as an alternative to octreotide. | |||
==References== | ==References== | ||
Latest revision as of 09:23, 9 August 2020
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Pulmonic regurgitation Microchapters |
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Diagnosis |
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Aravind Kuchkuntla, M.B.B.S[2], Aysha Anwar, M.B.B.S[3], Javaria Anwer M.D.[4]
Overview
Treatment of pulmonic regurgitation may be divided into medical and surgical treatment. Medical management of pulmonic regurgitation may include use of diuretics in patients with RV dysfunction. ACE inhibitors and beta blockers may be used to reverse neurohormonal activation and improve symptoms. Antibiotic prophylaxis may be indicated in certain conditions such as patients with cyanotic heart disease, prosthetic heart valves, rheumatic heart disease, and patients previously having sustained bacterial endocarditis. Among patients with carcinoid heart disease subcutaneously administered octreotide in 2–4 divided doses (50–1500 μg/day) provides symptomatic and biochemical benefit.
Medical Therapy
- There are no specific medical measures for the management of PR.
- Diuretics are recommended in patients with RV dysfunction or PAH for maintenance of fluid balance.[1]
- Among patients with repaired tetralogy of fallot, ACE inhibitors or beta-blockers are used to reverse the neuroharmonal activation and improve the symptoms.[2][3]
Anticoagulation
- Administration of systemic anticoagulation has led to risk reduction of major thromboembolic events among patients with mechanical valves. The risks reduced from 23 per 100 patient-years to[4]:
- 2.2 per 100 patient-years with antiplatelet therapy
- 1 per 100 patient-years with warfarin
- Among patients NYHA functional class I or II and a small prosthetic clot, short-term IV unfractionated heparin or continuous fibrinolytic therapy can be administered.[5]
- The treatment of choice for obstructive thrombosis among critically ill patients without serious comorbidity is urgent valve replacement. (European Society of Cardiology guidelines)[6]
Antiobiotic prophylaxis
The American Heart Association Recommendations on Prevention of Bacterial Endocarditis indicate that antibiotic prophylaxis is not necessary for pulmonic regurgitation in those patients with otherwise structurally normal pulmonic valves, particularly if there is no diastolic murmur. It should be noted, though, that those patients with the following conditions may warrant antibiotic prophylaxis:[7]
- Complex cyanotic heart disease
- Prosthetic heart valves
- Patients with congenital heart disease and pulmonic regurgitation
- Acquired pulmonic valve regurgitation as the result of rheumatic heart disease
- Patients with complex cyanotic heart disease
- In patients who have previously sustained bacterial endocarditis
- The antibiotic prophylaxis if required is reasonable within 6 months after the procedure.[8]
- Among patients with severe acute PR due to the large duct (such as in neonatal Ebstein's anomaly or post balloon dilation of pulmonary stenosis or perforation of valvar pulmonary atresia)[9][10]:
- If TR accompanies the situation, a circular shunt may occur leading to poor systemic blood flow. The treatment involves stopping the prostaglandins and urgent duct ligation among unstable patients.
- If tricuspid valve is competent, increasing ventilation, oxygen, and nitric oxide to cause pulmonary vasodilatation can reduce PR.
Heart failure therapy
- General measures for the treatment of heart failure include[11]:
- Diet: Salt and water restriction
- Monitoring: Weight and fluid balance monitoring
- Mobility: Mobility and compression stockings help prevent the development of deep venous thrombosis and leg edema.
- Right heart failure: A combination of loop diuretics and digoxin (may help with right ventricular contractility). Often, loop diuretics alone are enough to achieve sufficient fluid loss, but if additional diuresis is required, the judicious coadministration of a Thiazide diuretic may be administered with loop diuretics to achieve optimal fluid balance.
- To read more about the medical therapy utilized in heart failure, click here.
Carcinoid heart disease[11][12]
Subcutaneously administered octreotide in 2–4 divided doses (50–1500 μg/day) provides symptomatic and biochemical benefit. Octreotide (somatostatin analog) binds to somatostatin receptors, and reduces the vasoactive peptides that provoke carcinoid syndrome. Concomitant monitoring of BSL and blood glucose levels is required. Lanreotide (BIM23014, angiopeptin and somatuline) is a newer somatostatin analog, has an advantage of less frequent administrations, and can be used as an alternative to octreotide.
References
- ↑ Fauci, Anthony (2008). Harrison's principles of internal medicine. New York: McGraw-Hill Medical. ISBN 978-0071466332.
- ↑ Bolger AP, Sharma R, Li W, Leenarts M, Kalra PR, Kemp M; et al. (2002). "Neurohormonal activation and the chronic heart failure syndrome in adults with congenital heart disease". Circulation. 106 (1): 92–9. PMID 12093776.
- ↑ Davos CH, Davlouros PA, Wensel R, Francis D, Davies LC, Kilner PJ; et al. (2002). "Global impairment of cardiac autonomic nervous activity late after repair of tetralogy of Fallot". Circulation. 106 (12 Suppl 1): I69–75. PMID 12354712.
- ↑ Cannegieter SC, Rosendaal FR, Briët E (February 1994). "Thromboembolic and bleeding complications in patients with mechanical heart valve prostheses". Circulation. 89 (2): 635–41. doi:10.1161/01.cir.89.2.635. PMID 8313552.
- ↑ Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O'Gara PT, O'Rourke RA, Otto CM, Shah PM, Shanewise JS (October 2008). "2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". Circulation. 118 (15): e523–661. doi:10.1161/CIRCULATIONAHA.108.190748. PMID 18820172.
- ↑ Vahanian A, Baumgartner H, Bax J, Butchart E, Dion R, Filippatos G, Flachskampf F, Hall R, Iung B, Kasprzak J, Nataf P, Tornos P, Torracca L, Wenink A (January 2007). "Guidelines on the management of valvular heart disease: The Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology". Eur. Heart J. 28 (2): 230–68. doi:10.1093/eurheartj/ehl428. PMID 17259184.
- ↑ Seiler C (2004). "Management and follow up of prosthetic heart valves". Heart. 90 (7): 818–24. doi:10.1136/hrt.2003.025049. PMC 1768319. PMID 15201262.
- ↑ Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, Bolger A, Cabell CH, Takahashi M, Baltimore RS, Newburger JW, Strom BL, Tani LY, Gerber M, Bonow RO, Pallasch T, Shulman ST, Rowley AH, Burns JC, Ferrieri P, Gardner T, Goff D, Durack DT (October 2007). "Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group". Circulation. 116 (15): 1736–54. doi:10.1161/CIRCULATIONAHA.106.183095. PMID 17446442.
- ↑ Wald RM, Adatia I, Van Arsdell GS, Hornberger LK (September 2005). "Relation of limiting ductal patency to survival in neonatal Ebstein's anomaly". Am. J. Cardiol. 96 (6): 851–6. doi:10.1016/j.amjcard.2005.05.035. PMID 16169376.
- ↑ Chaturvedi RR, Redington AN (July 2007). "Pulmonary regurgitation in congenital heart disease". Heart. 93 (7): 880–9. doi:10.1136/hrt.2005.075234. PMC 1994453. PMID 17569817.
- ↑ 11.0 11.1 Fox DJ, Khattar RS (October 2004). "Carcinoid heart disease: presentation, diagnosis, and management". Heart. 90 (10): 1224–8. doi:10.1136/hrt.2004.040329. PMC 1768473. PMID 15367531.
- ↑ Janmohamed S, Bloom SR (April 1997). "Carcinoid tumours". Postgrad Med J. 73 (858): 207–14. doi:10.1136/pgmj.73.858.207. PMC 2431281. PMID 9156122.