Aortic coarctation medical therapy: Difference between revisions
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{{Aortic coarctation}} | {{Aortic coarctation}} | ||
{{CMG}}; '''Associate Editor(s)-In-Chief:''' [[Priyamvada Singh|Priyamvada Singh, M.B.B.S.]][mailto: | {{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== | ||
The treatment choice depends on the patients age of presentation, severity, the location of the coarctation and other associated anomalies. For children who present early, the role of medical management is for stablizing the patient for surgery. However, in older kids and adolescent presenting with hypertension treatment is guided towards correction of hypertension and other associated anomalies. | The treatment choice depends on the patients age of presentation, severity, the location of the coarctation and other associated anomalies. For children who present early, the role of medical management is for stablizing the patient for surgery. However, in older kids and adolescent presenting with hypertension treatment is guided towards correction of hypertension and other associated anomalies. [[Beta blocker]] is treatment of choice for both pre and post operative [[hypertension]]. | ||
==Medical | ==Medical Therapy== | ||
===Early | ===Early Presentation=== | ||
Treatment in patients with early presentation of coarctation of aorta is supportive, symptomatic and the aim is to stabilize the patient for surgical procedure or catheter intervention. | Treatment in patients with early presentation of coarctation of aorta is supportive, symptomatic and the aim is to stabilize the patient for surgical procedure or catheter intervention. | ||
* Ventilatory support in patients with respiratory distress | * Ventilatory support in patients with respiratory distress | ||
* Congestive heart failure - | * [[Congestive heart failure]] - diuretics, Ionotropes | ||
* Hypotension - Ionotropes | * [[Hypotension]] - [[Ionotropes]] | ||
* PgE1 (prostaglandin E1) - | * PgE1 ([[prostaglandin E1]]) - given to keep the ductus arteriosus patent. | ||
* In patients with other associated cardiac defects if the coarctation has a significantly adverse effect on the clinical status, the coarctation should be initially relieved with surgery or balloon angioplasty and the patient reassessed with regard to need for intervention for the associated defects. | * In patients with other associated cardiac defects if the coarctation has a significantly adverse effect on the clinical status, the coarctation should be initially relieved with surgery or balloon angioplasty and the patient reassessed with regard to need for intervention for the associated defects. | ||
===Late | ===Late Presentation=== | ||
Late presenters usually have hypertension. Beta blocker is the treatment of choice for hypertension in these patients both pre and post operatively. | Late presenters usually have hypertension. Beta blocker is the treatment of choice for hypertension in these patients both pre and post operatively. <ref name="pmid15288162">{{cite journal |author=López-Sendón J, Swedberg K, McMurray J, Tamargo J, Maggioni AP, Dargie H, Tendera M, Waagstein F, Kjekshus J, Lechat P, Torp-Pedersen C |title=Expert consensus document on beta-adrenergic receptor blockers |journal=[[European Heart Journal]] |volume=25 |issue=15 |pages=1341–62 |year=2004 |month=August |pmid=15288162 |doi=10.1016/j.ehj.2004.06.002 |url=http://eurheartj.oxfordjournals.org/cgi/pmidlookup?view=long&pmid= |accessdate=2012-04-14}}</ref> | ||
====Preoperative==== | ====Preoperative==== | ||
* Beta blockers are the treatment of choice. | * Beta blockers are the treatment of choice. | ||
* Caution should be taken as too much control of hypertension in upper limb can cause hypotension in lower limbs. | * Caution should be taken as too much control of hypertension in upper limb can cause hypotension in lower limbs. | ||
* Surgical treatment of the lesion should not be delayed for the correction of hypertension. | * Surgical treatment of the lesion should not be delayed for the correction of hypertension. <ref name="pmid8541158">{{cite journal |author=Rao PS |title=Should balloon angioplasty be used instead of surgery for native aortic coarctation? |journal=[[British Heart Journal]] |volume=74 |issue=6 |pages=578–9 |year=1995 |month=December |pmid=8541158 |pmc=484108 |doi= |url=http://heart.bmj.com/cgi/pmidlookup?view=long&pmid=8541158 |accessdate=2012-04-14}}</ref> | ||
==== | ====Postoperative==== | ||
* Immediate post operative hypertension - use short-term vasodilators for e.g. [[sodium nitroprusside]], or intravenous beta-blockers like [[esmolol]]. | |||
* Long-term antihypertensive post surgery | |||
** Monotherapy with [[beta-blockers]] | |||
** [[ACE inhibitors]] or [[angiotensin II antagonists]] may be added if hypertension continues with beta-blocker monotherapy. | |||
====Contraindicated medications==== | |||
{{MedCondContrAbs|MedCond = Compensatory hypertension due to aortic coarctation|Nitroprusside}} | |||
==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 Key Issues to Evaluate and Follow-Up (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> === | |||
{|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.''' Lifelong cardiology follow-up is recommended for all patients with aortic coarctation (repaired or not), including an evaluation by or consultation with a cardiologist with expertise in ACHD. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki> | |||
|- | |||
| bgcolor="LightGreen"|<nowiki>"</nowiki> '''2.''' Patients who have had surgical repair of coarctation at the aorta or percutaneous intervention for coarctation of the aorta should have at least yearly follow-up. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki> | |||
|- | |||
| bgcolor="LightGreen"|<nowiki>"</nowiki> '''3.''' Even if the coarctation repair appears to be satisfactory, late postoperative thoracic aortic imaging should be performed to assess for aortic dilatation or aneurysm formation. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki> | |||
|- | |||
| bgcolor="LightGreen"|<nowiki>"</nowiki> '''4.''' Patients should be observed closely for the appearance or reappearance of resting or exercise-induced systemic arterial hypertension, which should be treated aggressively after recoarctation is excluded. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki> | |||
|- | |||
| bgcolor="LightGreen"|<nowiki>"</nowiki> '''5.''' Evaluation of the coarctation repair site by MRI/CT should be performed at intervals of 5 years or less, depending on the specific anatomic findings before and after repair. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki> | |||
|} | |||
{|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.''' Routine exercise testing may be performed at intervals determined by consultation with the regional ACHD center. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki> | |||
|} | |||
==References== | ==References== | ||
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{{WH}} | {{WH}} | ||
{{WS}} | {{WS}} | ||
[[CME Category::Cardiology]] | |||
[[Category:Cardiology]] | [[Category:Cardiology]] | ||
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[[Category:Disease]] | [[Category:Disease]] | ||
[[Category:Congenital heart disease]] | [[Category:Congenital heart disease]] | ||
Latest revision as of 22:18, 14 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
The treatment choice depends on the patients age of presentation, severity, the location of the coarctation and other associated anomalies. For children who present early, the role of medical management is for stablizing the patient for surgery. However, in older kids and adolescent presenting with hypertension treatment is guided towards correction of hypertension and other associated anomalies. Beta blocker is treatment of choice for both pre and post operative hypertension.
Medical Therapy
Early Presentation
Treatment in patients with early presentation of coarctation of aorta is supportive, symptomatic and the aim is to stabilize the patient for surgical procedure or catheter intervention.
- Ventilatory support in patients with respiratory distress
- Congestive heart failure - diuretics, Ionotropes
- Hypotension - Ionotropes
- PgE1 (prostaglandin E1) - given to keep the ductus arteriosus patent.
- In patients with other associated cardiac defects if the coarctation has a significantly adverse effect on the clinical status, the coarctation should be initially relieved with surgery or balloon angioplasty and the patient reassessed with regard to need for intervention for the associated defects.
Late Presentation
Late presenters usually have hypertension. Beta blocker is the treatment of choice for hypertension in these patients both pre and post operatively. [1]
Preoperative
- Beta blockers are the treatment of choice.
- Caution should be taken as too much control of hypertension in upper limb can cause hypotension in lower limbs.
- Surgical treatment of the lesion should not be delayed for the correction of hypertension. [2]
Postoperative
- Immediate post operative hypertension - use short-term vasodilators for e.g. sodium nitroprusside, or intravenous beta-blockers like esmolol.
- Long-term antihypertensive post surgery
- Monotherapy with beta-blockers
- ACE inhibitors or angiotensin II antagonists may be added if hypertension continues with beta-blocker monotherapy.
Contraindicated medications
Compensatory hypertension due to aortic coarctation is considered an absolute contraindication to the use of the following medications:
2008 ACC/AHA Guidelines for the Management of Adults With Congenital Heart Disease (DO NOT EDIT)[3]
Recommendations for Key Issues to Evaluate and Follow-Up (DO NOT EDIT)[3]
| Class I |
| " 1. Lifelong cardiology follow-up is recommended for all patients with aortic coarctation (repaired or not), including an evaluation by or consultation with a cardiologist with expertise in ACHD. (Level of Evidence: C) " |
| " 2. Patients who have had surgical repair of coarctation at the aorta or percutaneous intervention for coarctation of the aorta should have at least yearly follow-up. (Level of Evidence: C) " |
| " 3. Even if the coarctation repair appears to be satisfactory, late postoperative thoracic aortic imaging should be performed to assess for aortic dilatation or aneurysm formation. (Level of Evidence: B) " |
| " 4. Patients should be observed closely for the appearance or reappearance of resting or exercise-induced systemic arterial hypertension, which should be treated aggressively after recoarctation is excluded. (Level of Evidence: B) " |
| " 5. Evaluation of the coarctation repair site by MRI/CT should be performed at intervals of 5 years or less, depending on the specific anatomic findings before and after repair. (Level of Evidence: C) " |
| Class I |
| " 1. Routine exercise testing may be performed at intervals determined by consultation with the regional ACHD center. (Level of Evidence: C) " |
References
- ↑ López-Sendón J, Swedberg K, McMurray J, Tamargo J, Maggioni AP, Dargie H, Tendera M, Waagstein F, Kjekshus J, Lechat P, Torp-Pedersen C (2004). "Expert consensus document on beta-adrenergic receptor blockers". European Heart Journal. 25 (15): 1341–62. doi:10.1016/j.ehj.2004.06.002. PMID 15288162. Retrieved 2012-04-14. Unknown parameter
|month=ignored (help) - ↑ Rao PS (1995). "Should balloon angioplasty be used instead of surgery for native aortic coarctation?". British Heart Journal. 74 (6): 578–9. PMC 484108. PMID 8541158. Retrieved 2012-04-14. Unknown parameter
|month=ignored (help) - ↑ 3.0 3.1 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.