Atrial septal defect ostium primum medical therapy
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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 medical therapy usage in patients with atrial septal defects. Medical therapy in patients of atrial septal defect is administered in certain conditions like arrhythmias [1]. Also, medical therapy can be used to manage conditions associated with atrial septal defects.
- In asymptomatic patients with small shunts and normal right ventricle size generally no medical therapy is required. Routine follow-up assessment of symptoms like arrhythmia and 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 with atrial fibrillation, antiarrhythmic and anticoagulation therapy is recommended.
Medical Therapy for 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]
Medical Therapy for Migraine
Some recent research has 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.[6] [7] 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 betweenPFO 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 research has noted that treatment of patent foramen ovale can reduce the severity of migraine symptoms.[8][9]
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)[10]
Recommendations for Medical Therapy (DO NOT EDIT)[10]
| 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.
- ↑ 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.
- ↑ 10.0 10.1 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.