Atrial septal defect medical therapy: Difference between revisions
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===ASD and Migraine with Aura (MHA)=== | ===ASD and Migraine with Aura (MHA)=== | ||
A relationship between migraine with aura and [[right-to-left shunt]] has been documented in many studies.<ref name="Anzola-1999">{{Cite journal | last1 = Anzola | first1 = GP. | last2 = Magoni | first2 = M. | last3 = Guindani | first3 = M. | last4 = Rozzini | first4 = L. | last5 = Dalla Volta | first5 = G. | title = Potential source of cerebral embolism in migraine with aura: a transcranial Doppler study. | journal = Neurology | volume = 52 | issue = 8 | pages = 1622-5 | month = May | year = 1999 | doi = | PMID = 10331688 }}</ref> Several pathogenetic mechanisms have been explained, namely: | A relationship between migraine with aura and [[right-to-left shunt]] has been documented in many studies.<ref name="Anzola-1999">{{Cite journal | last1 = Anzola | first1 = GP. | last2 = Magoni | first2 = M. | last3 = Guindani | first3 = M. | last4 = Rozzini | first4 = L. | last5 = Dalla Volta | first5 = G. | title = Potential source of cerebral embolism in migraine with aura: a transcranial Doppler study. | journal = Neurology | volume = 52 | issue = 8 | pages = 1622-5 | month = May | year = 1999 | doi = | PMID = 10331688 }}</ref> Several pathogenetic mechanisms have been explained, namely: | ||
* Co-inheritance - An autosomal dominant inheritance of atrial shunts was linked to the inheritance of MHA.<ref name="Schwerzmann-2007">{{Cite journal | last1 = Schwerzmann | first1 = M. | last2 = Nedeltchev | first2 = K. | last3 = Meier | first3 = B. | title = Patent foramen ovale closure: a new therapy for migraine. | journal = Catheter Cardiovasc Interv | volume = 69 | issue = 2 | pages = 277-84 | month = Feb | year = 2007 | doi = 10.1002/ccd.20966 | PMID = 17253601 }}</ref> | * '''Co-inheritance''' - An autosomal dominant inheritance of atrial shunts was linked to the inheritance of MHA.<ref name="Schwerzmann-2007">{{Cite journal | last1 = Schwerzmann | first1 = M. | last2 = Nedeltchev | first2 = K. | last3 = Meier | first3 = B. | title = Patent foramen ovale closure: a new therapy for migraine. | journal = Catheter Cardiovasc Interv | volume = 69 | issue = 2 | pages = 277-84 | month = Feb | year = 2007 | doi = 10.1002/ccd.20966 | PMID = 17253601 }}</ref> | ||
* Increased neuronal excitability - Right-to-left shunting of blood exposes neurons to microemboli or vasoactive peptides such as [[serotonin]], which triggers migraine attacks by lowering the neuronal excitability threshold. | * '''Increased neuronal excitability''' - Right-to-left shunting of blood exposes neurons to microemboli or vasoactive peptides such as [[serotonin]], which triggers migraine attacks by lowering the neuronal excitability threshold. | ||
* Reduced plasma [[atrial natriuretic peptide]] - Atrial natriuretic peptide, which is released by the atrial myocytes in response to atrial stretch, is known to play roles in natriuresis, inhibition of platelet aggregation<ref name="Ulker-1995">{{Cite journal | last1 = Ulker | first1 = S. | last2 = Akgür | first2 = S. | last3 = Evinç | first3 = A. | last4 = Soykan | first4 = N. | last5 = Koşay | first5 = S. | title = Platelet aggregation and atrial natriuretic peptide. | journal = Gen Pharmacol | volume = 26 | issue = 6 | pages = 1409-12 | month = Oct | year = 1995 | doi = | PMID = 7590139 }}</ref> and vasoreactivity of vascular smooth muscles to vasoconstrictor substances. | * '''Reduced plasma [[atrial natriuretic peptide]]''' - Atrial natriuretic peptide, which is released by the atrial myocytes in response to atrial stretch, is known to play roles in natriuresis, inhibition of platelet aggregation<ref name="Ulker-1995">{{Cite journal | last1 = Ulker | first1 = S. | last2 = Akgür | first2 = S. | last3 = Evinç | first3 = A. | last4 = Soykan | first4 = N. | last5 = Koşay | first5 = S. | title = Platelet aggregation and atrial natriuretic peptide. | journal = Gen Pharmacol | volume = 26 | issue = 6 | pages = 1409-12 | month = Oct | year = 1995 | doi = | PMID = 7590139 }}</ref> and lowers vasoreactivity of vascular smooth muscles to vasoconstrictor substances. As a result of increased blood volume observed in atrial shunts, patients with ASD have elevated levels of ANP, which subsequently normalizes following closure in majority of patients.<ref name="Erbay-2004">{{Cite journal | last1 = Erbay | first1 = AR. | last2 = Yilmaz | first2 = MB. | last3 = Balci | first3 = M. | last4 = Sabah | first4 = I. | title = Atrial natriuretic peptide levels in adult patients before and after surgery for correction of atrial septal defects: relationship with atrial arrhythmias. | journal = Clin Sci (Lond) | volume = 107 | issue = 3 | pages = 297-302 | month = Sep | year = 2004 | doi = 10.1042/CS20040141 | PMID = 15142035 }}</ref> As a direct result of this, migraine auras may be facilitated due to the lack of vasodilatory and antiplatelet activities in vulnerable patients. | ||
A recent research suggested that a proportion of cases of [[migraine]] may be caused by [[Patent foramen ovale|patent foramen ovale]]. While the exact mechanism remains unclear, closure of a [[PFO]] can reduce symptoms in certain cases.<ref>{{cite journal | author = Adams H | title = Patent foramen ovale: paradoxical embolism and paradoxical data. | journal = Mayo Clin Proc | volume = 79 | issue = 1 | pages = 15-20 | year = 2004 | id = PMID 14708944}}</ref><ref>{{cite journal | author = Azarbal B, Tobis J, Suh W, Chan V, Dao C, Gaster R | title = Association of interatrial shunts and migraine headaches: impact of transcatheter closure. | journal = J Am Coll Cardiol | volume = 45 | issue = 4 | pages = 489-92 | year = 2005 | id = PMID 15708691}}</ref> This remains controversial. 20% of the general population have a [[PFO]], which for the most part, is asymptomatic. 20% of the female population have migraines. And, the [[placebo effect]] in migraine typically averages around 40%. The high frequency of these facts makes statistically significant relationships between [[PFO]] and migraine difficult (i.e. the relationship may just be chance or coincidence). | A recent research suggested that a proportion of cases of [[migraine]] may be caused by [[Patent foramen ovale|patent foramen ovale]]. While the exact mechanism remains unclear, closure of a [[PFO]] can reduce symptoms in certain cases.<ref>{{cite journal | author = Adams H | title = Patent foramen ovale: paradoxical embolism and paradoxical data. | journal = Mayo Clin Proc | volume = 79 | issue = 1 | pages = 15-20 | year = 2004 | id = PMID 14708944}}</ref><ref>{{cite journal | author = Azarbal B, Tobis J, Suh W, Chan V, Dao C, Gaster R | title = Association of interatrial shunts and migraine headaches: impact of transcatheter closure. | journal = J Am Coll Cardiol | volume = 45 | issue = 4 | pages = 489-92 | year = 2005 | id = PMID 15708691}}</ref> This remains controversial. 20% of the general population have a [[PFO]], which for the most part, is asymptomatic. 20% of the female population have migraines. And, the [[placebo effect]] in migraine typically averages around 40%. The high frequency of these facts makes statistically significant relationships between [[PFO]] and migraine difficult (i.e. the relationship may just be chance or coincidence). | ||
Revision as of 17:04, 31 January 2014
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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 with Aura (MHA)
A relationship between migraine with aura and right-to-left shunt has been documented in many studies.[6] Several pathogenetic mechanisms have been explained, namely:
- Co-inheritance - An autosomal dominant inheritance of atrial shunts was linked to the inheritance of MHA.[7]
- Increased neuronal excitability - Right-to-left shunting of blood exposes neurons to microemboli or vasoactive peptides such as serotonin, which triggers migraine attacks by lowering the neuronal excitability threshold.
- Reduced plasma atrial natriuretic peptide - Atrial natriuretic peptide, which is released by the atrial myocytes in response to atrial stretch, is known to play roles in natriuresis, inhibition of platelet aggregation[8] and lowers vasoreactivity of vascular smooth muscles to vasoconstrictor substances. As a result of increased blood volume observed in atrial shunts, patients with ASD have elevated levels of ANP, which subsequently normalizes following closure in majority of patients.[9] As a direct result of this, migraine auras may be facilitated due to the lack of vasodilatory and antiplatelet activities in vulnerable patients.
A recent research suggested that a proportion of cases of migraine may be caused by patent foramen ovale. While the exact mechanism remains unclear, closure of a PFO can reduce symptoms in certain cases.[10][11] This remains controversial. 20% of the general population have a PFO, which for the most part, is asymptomatic. 20% of the female population have migraines. And, the placebo effect in migraine typically averages around 40%. The high frequency of these facts makes statistically significant relationships between PFO and migraine difficult (i.e. the relationship may just be chance or coincidence).
Although there is no direct evidence to link migraines and atrial septal defects, some researchers noted that treatment of patent foramen ovale can reduce the severity and frequency of migraine episodes,[12][13][14] while some reported cases of recurrent migraine attacks with prolonged aura symptoms following closure,[15][16] especially with the closure of secundum ASD rather than patent foramen ovale.
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: Botuliunum 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)[17]
Recommendations for Medical Therapy (DO NOT EDIT)[17]
| 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.
- ↑ Anzola, GP.; Magoni, M.; Guindani, M.; Rozzini, L.; Dalla Volta, G. (1999). "Potential source of cerebral embolism in migraine with aura: a transcranial Doppler study". Neurology. 52 (8): 1622–5. PMID 10331688. Unknown parameter
|month=ignored (help) - ↑ Schwerzmann, M.; Nedeltchev, K.; Meier, B. (2007). "Patent foramen ovale closure: a new therapy for migraine". Catheter Cardiovasc Interv. 69 (2): 277–84. doi:10.1002/ccd.20966. PMID 17253601. Unknown parameter
|month=ignored (help) - ↑ Ulker, S.; Akgür, S.; Evinç, A.; Soykan, N.; Koşay, S. (1995). "Platelet aggregation and atrial natriuretic peptide". Gen Pharmacol. 26 (6): 1409–12. PMID 7590139. Unknown parameter
|month=ignored (help) - ↑ Erbay, AR.; Yilmaz, MB.; Balci, M.; Sabah, I. (2004). "Atrial natriuretic peptide levels in adult patients before and after surgery for correction of atrial septal defects: relationship with atrial arrhythmias". Clin Sci (Lond). 107 (3): 297–302. doi:10.1042/CS20040141. PMID 15142035. Unknown parameter
|month=ignored (help) - ↑ Adams H (2004). "Patent foramen ovale: paradoxical embolism and paradoxical data". Mayo Clin Proc. 79 (1): 15–20. PMID 14708944.
- ↑ Azarbal B, Tobis J, Suh W, Chan V, Dao C, Gaster R (2005). "Association of interatrial shunts and migraine headaches: impact of transcatheter closure". J Am Coll Cardiol. 45 (4): 489–92. PMID 15708691.
- ↑ Azarbal B, Tobis J, Suh W, Chan V, Dao C, Gaster R (2005). "Association of interatrial shunts and migraine headaches: impact of transcatheter closure". J Am Coll Cardiol. 45 (4): 489–92. PMID 15708691.
- ↑ Adams H (2004). "Patent foramen ovale: paradoxical embolism and paradoxical data". Mayo Clin Proc. 79 (1): 15–20. PMID 14708944.
- ↑ Giardini, A.; Donti, A.; Formigari, R.; Salomone, L.; Palareti, G.; Guidetti, D.; Picchio, FM. (2006). "Long-term efficacy of transcatheter patent foramen ovale closure on migraine headache with aura and recurrent stroke". Catheter Cardiovasc Interv. 67 (4): 625–9. doi:10.1002/ccd.20699. PMID 16548006. Unknown parameter
|month=ignored (help) - ↑ Riederer, F.; Kaya, M.; Christina, P.; Harald, G.; Peter, W. "Migraine with aura related to closure of atrial septal defects". Headache. 45 (7): 953–6. doi:10.1111/j.1526-4610.2005.05166_2.x. PMID 15985118.
- ↑ Yankovsky, AE.; Kuritzky, A. (2003). "Transformation into daily migraine with aura following transcutaneous atrial septal defect closure". Headache. 43 (5): 496–8. PMID 12752756. Unknown parameter
|month=ignored (help) - ↑ 17.0 17.1 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.