Atrial septal defect medical therapy: Difference between revisions
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{{Atrial septal defect}} | {{Atrial septal defect}} | ||
{{CMG}}; '''Associate | {{CMG}}; '''Associate Editor(s)-In-Chief:''' [[Priyamvada Singh|Priyamvada Singh, M.B.B.S.]] [mailto:psingh13579@gmail.com]; {{CZ}} '''Assistant Editor(s)-In-Chief:''' [[Kristin Feeney|Kristin Feeney, B.S.]] [mailto:kfeeney@elon.edu] | ||
==Overview== | ==Overview== | ||
Definitive treatment of [[atrial septal defect]] involves surgical closure of the defect. Medical therapy has a limited role in the management of ASD, and is often used to manage complications like [[arrhythmia]], [[congestive heart failure]] and other comorbidities associated with atrial septal defects such as [[stroke]] and [[migraine]]. | |||
==Medical Therapy== | |||
There are no widely used guidelines for drug usage in patients with atrial septal defects. Medical therapy in patients with atrial septal defect is administered in certain conditions like [[arrhythmia]]s <ref name="pmid8653857">{{cite journal| author=Prystowsky EN, Benson DW, Fuster V, Hart RG, Kay GN, Myerburg RJ et al.| title=Management of patients with atrial fibrillation. A Statement for Healthcare Professionals. From the Subcommittee on Electrocardiography and Electrophysiology, American Heart Association. | journal=Circulation | year= 1996 | volume= 93 | issue= 6 | pages= 1262-77 | pmid=8653857 | doi= | pmc= |url= }} </ref>. | |||
==Medical | |||
There are no widely used guidelines for | |||
* In asymptomatic patients with small shunts and normal right ventricle size | * In asymptomatic patients with small shunts and normal right ventricle size, no medical therapy is required. Routine follow-up assessment of symptoms like [[arrhythmia]], [[Cryptogenic stroke|paradoxical embolic]] events should be done. Also, a repeat [[echocardiogram]] should be obtained every 2 to 3 years. | ||
* Treatment of atrial arrhythmia and restoration of sinus rhythm is recommended. In cases | * Treatment of atrial arrhythmia and restoration of [[sinus rhythm]] is recommended. In cases of [[atrial fibrillation]], [[antiarrhythmic]] and [[anticoagulation]] therapy is recommended. | ||
== | ===ASD and Stroke=== | ||
[[Aspirin]] has been found to decrease the incidence of recurrent [[stroke]] and [[transient ischemic attack]]s in patients with atrial septal defect and [[patent foramen ovale]] <ref name="pmid11742048">{{cite journal| author=Mas JL, Arquizan C, Lamy C, Zuber M, Cabanes L, Derumeaux G et al.| title=Recurrent cerebrovascular events associated with patent foramen ovale, atrial septal aneurysm, or both. | journal=N Engl J Med | year= 2001 | volume= 345 | issue= 24 |pages= 1740-6 | pmid=11742048 | doi=10.1056/NEJMoa011503 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11742048 }} </ref>. The American Heart Association guidelines support the utilization of sustained [[warfarin]] therapy in high-risk [[atrial septal defect]] patients.<ref name="pmid18574275">{{cite journal| author=Albers GW, Amarenco P, Easton JD, Sacco RL, Teal P, American College of Chest Physicians| title=Antithrombotic and thrombolytic therapy for ischemic stroke: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). | journal=Chest | year= 2008 | volume= 133 | issue= 6 Suppl | pages= 630S-669S | pmid=18574275 |doi=10.1378/chest.08-0720 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18574275 }} </ref> | |||
{{ | * Researchers have investigated the justification for [[aspirin]] therapy in patients with atrial septal defects and [[patent foramen ovale]] who have had [[stroke]] or a [[transient ischemic attack]]. [[Aspirin]] therapy was observed to have an effective role in reducing the incidence of recurrent [[stroke]] after four years.<ref name="pmid11742048">{{cite journal| author=Mas JL, Arquizan C, Lamy C, Zuber M, Cabanes L, Derumeaux G et al.| title=Recurrent cerebrovascular events associated with patent foramen ovale, atrial septal aneurysm, or both. | journal=N Engl J Med | year= 2001 | volume= 345 | issue= 24 | pages= 1740-6 |pmid=11742048 | doi=10.1056/NEJMoa011503 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11742048}} </ref> | ||
* Another pharmacologic intervention study indicated that both [[aspirin]] and [[warfarin]] therapy were effective. <ref name="pmid12045168">{{cite journal|author=Homma S, Sacco RL, Di Tullio MR, Sciacca RR, Mohr JP, PFO in Cryptogenic Stroke Study (PICSS) Investigators| title=Effect of medical treatment in stroke patients with patent foramen ovale: patent foramen ovale in Cryptogenic Stroke Study. | journal=Circulation | year= 2002 | volume= 105 | issue= 22 | pages= 2625-31 | pmid=12045168 | doi= | pmc= | url= }} </ref> | |||
* The [[AHA]] guidelines support the utilization of sustained warfarin therapy in high-risk [[atrial septal defect]] patients. <ref name="pmid20966421">{{cite journal| author=Furie KL, Kasner SE, Adams RJ, Albers GW, Bush RL, Fagan SC et al.| title=Guidelines for the prevention of stroke in patients with stroke or transient ischemic attack: a guideline for healthcare professionals from the american heart association/american stroke association. | journal=Stroke | year= 2011 | volume= 42 | issue= 1 | pages= 227-76 | pmid=20966421 | doi=10.1161/STR.0b013e3181f7d043 | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20966421 }} </ref> | |||
===ASD and Migraine=== | |||
Effective pharmacologic therapies for migraine prevention include: | |||
*Anti-hypertensives: [[Beta-blockers|Beta blockers]] ([[propranolol]], [[timolol]], [[metoprolol]], [[nadolol]], and [[atenolol]]), [[Calcium channel blocker|calcium channel blockers]] ([[verapamil]], [[nifedipine]], and [[nimodipine]]), and [[ACE_inhibitors|angiotensin converting enzyme inhibitors/angiotensin II receptor blockers]] ([[lisinopril]], [[candesartan]]) | |||
*[[Antidepressant|Anti-depressants]]: [[Amitriptyline]], [[venlafaxine]], [[nortriptyline]], [[doxepin]], [[protriptyline]] | |||
*Anti-convulsants: [[Valproate]], [[gabapentin]], [[topiramate]] | |||
*Other [[prophylaxis]]: [[Botulinum toxin]], [[butterbur]], [[coenzyme Q10]], [[feverfew]], [[magnesium]], [[methysergide]], [[opioids]], [[pizotifen]],[[riboflavin]] | |||
==2008 ACC/AHA Guidelines for the Management of Adults With Congenital Heart Disease (DO NOT EDIT)<ref name="pmid19038677">{{cite journal| author=Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA et al.| title=ACC/AHA 2008 guidelines for the management of adults with congenital heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines on the Management of Adults With Congenital Heart Disease). Developed in Collaboration With the American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. | journal=J Am Coll Cardiol | year= 2008 | volume= 52 | issue= 23 | pages= e1-121 | pmid=19038677 | doi=10.1016/j.jacc.2008.10.001 | pmc=|url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19038677 }} </ref> == | |||
===Recommendations for Medical Therapy (DO NOT EDIT)<ref name="pmid19038677">{{cite journal| author=Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA et al.| title=ACC/AHA 2008 guidelines for the management of adults with congenital heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines on the Management of Adults With Congenital Heart Disease). Developed in Collaboration With the American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. | journal=J Am Coll Cardiol | year= 2008 | volume= 52|issue= 23 | pages= e1-121 | pmid=19038677 | doi=10.1016/j.jacc.2008.10.001 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19038677 }} </ref>=== | |||
2 Rate control and anticoagulation are recommended if sinus rhythm cannot be maintained by medical or interventional means. (Level of Evidence: A | {|class="wikitable" | ||
|- | |||
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]] | |||
|- | |||
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' [[Cardioversion]] after appropriate [[anticoagulation]] is recommended to attempt restoration of the [[sinus rhythm]] if [[atrial fibrillation]] occurs. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])'' <nowiki>"</nowiki> | |||
|- | |||
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' Rate control and [[anticoagulation]] are recommended if [[sinus rhythm]] cannot be maintained by medical or interventional means. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki> | |||
|} | |||
==References== | ==References== | ||
{{ | {{reflist|2}} | ||
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Latest revision as of 01:56, 15 March 2016
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Priyamvada Singh, M.B.B.S. [2]; Cafer Zorkun, M.D., Ph.D. [3] Assistant Editor(s)-In-Chief: Kristin Feeney, B.S. [4]
Overview
Definitive treatment of atrial septal defect involves surgical closure of the defect. Medical therapy has a limited role in the management of ASD, and is often used to manage complications like arrhythmia, congestive heart failure and other comorbidities associated with atrial septal defects such as stroke and migraine.
Medical Therapy
There are no widely used guidelines for drug usage in patients with atrial septal defects. Medical therapy in patients with atrial septal defect is administered in certain conditions like arrhythmias [1].
- In asymptomatic patients with small shunts and normal right ventricle size, no medical therapy is required. Routine follow-up assessment of symptoms like arrhythmia, paradoxical embolic events should be done. Also, a repeat echocardiogram should be obtained every 2 to 3 years.
- Treatment of atrial arrhythmia and restoration of sinus rhythm is recommended. In cases of atrial fibrillation, antiarrhythmic and anticoagulation therapy is recommended.
ASD and Stroke
Aspirin has been found to decrease the incidence of recurrent stroke and transient ischemic attacks in patients with atrial septal defect and patent foramen ovale [2]. The American Heart Association guidelines support the utilization of sustained warfarin therapy in high-risk atrial septal defect patients.[3]
- Researchers have investigated the justification for aspirin therapy in patients with atrial septal defects and patent foramen ovale who have had stroke or a transient ischemic attack. Aspirin therapy was observed to have an effective role in reducing the incidence of recurrent stroke after four years.[2]
- Another pharmacologic intervention study indicated that both aspirin and warfarin therapy were effective. [4]
- The AHA guidelines support the utilization of sustained warfarin therapy in high-risk atrial septal defect patients. [5]
ASD and Migraine
Effective pharmacologic therapies for migraine prevention include:
- Anti-hypertensives: Beta blockers (propranolol, timolol, metoprolol, nadolol, and atenolol), calcium channel blockers (verapamil, nifedipine, and nimodipine), and angiotensin converting enzyme inhibitors/angiotensin II receptor blockers (lisinopril, candesartan)
- Anti-depressants: Amitriptyline, venlafaxine, nortriptyline, doxepin, protriptyline
- Anti-convulsants: Valproate, gabapentin, topiramate
- Other prophylaxis: Botulinum toxin, butterbur, coenzyme Q10, feverfew, magnesium, methysergide, opioids, pizotifen,riboflavin
2008 ACC/AHA Guidelines for the Management of Adults With Congenital Heart Disease (DO NOT EDIT)[6]
Recommendations for Medical Therapy (DO NOT EDIT)[6]
| Class I |
| "1. Cardioversion after appropriate anticoagulation is recommended to attempt restoration of the sinus rhythm if atrial fibrillation occurs. (Level of Evidence: A) " |
| "2. Rate control and anticoagulation are recommended if sinus rhythm cannot be maintained by medical or interventional means. (Level of Evidence: A)" |
References
- ↑ Prystowsky EN, Benson DW, Fuster V, Hart RG, Kay GN, Myerburg RJ; et al. (1996). "Management of patients with atrial fibrillation. A Statement for Healthcare Professionals. From the Subcommittee on Electrocardiography and Electrophysiology, American Heart Association". Circulation. 93 (6): 1262–77. PMID 8653857.
- ↑ 2.0 2.1 Mas JL, Arquizan C, Lamy C, Zuber M, Cabanes L, Derumeaux G; et al. (2001). "Recurrent cerebrovascular events associated with patent foramen ovale, atrial septal aneurysm, or both". N Engl J Med. 345 (24): 1740–6. doi:10.1056/NEJMoa011503. PMID 11742048.
- ↑ Albers GW, Amarenco P, Easton JD, Sacco RL, Teal P, American College of Chest Physicians (2008). "Antithrombotic and thrombolytic therapy for ischemic stroke: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition)". Chest. 133 (6 Suppl): 630S–669S. doi:10.1378/chest.08-0720. PMID 18574275.
- ↑ Homma S, Sacco RL, Di Tullio MR, Sciacca RR, Mohr JP, PFO in Cryptogenic Stroke Study (PICSS) Investigators (2002). "Effect of medical treatment in stroke patients with patent foramen ovale: patent foramen ovale in Cryptogenic Stroke Study". Circulation. 105 (22): 2625–31. PMID 12045168.
- ↑ Furie KL, Kasner SE, Adams RJ, Albers GW, Bush RL, Fagan SC; et al. (2011). "Guidelines for the prevention of stroke in patients with stroke or transient ischemic attack: a guideline for healthcare professionals from the american heart association/american stroke association". Stroke. 42 (1): 227–76. doi:10.1161/STR.0b013e3181f7d043. PMID 20966421.
- ↑ 6.0 6.1 Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA; et al. (2008). "ACC/AHA 2008 guidelines for the management of adults with congenital heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines on the Management of Adults With Congenital Heart Disease). Developed in Collaboration With the American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". J Am Coll Cardiol. 52 (23): e1–121. doi:10.1016/j.jacc.2008.10.001. PMID 19038677.