Farmacoterapia en el curso del embarazo y lactancia. Parte IV. Fármacos de su uso cardiovascular / Pharmacotherapy in pregnancy and breast feedind. Part IV. Cardiovascular drugs

En este artículo se desarrollas el tema de la farmacoterapia cardiovascular en el curso del embarazo y la lactancia. Se exponen los fármacos de uso más frecuente usados en la hipertensión arterial como la alfametildopa y la hidralazina así como los betabloqueantes, calcioantagonistas y diuréticos. Tambien se mencionan por sus efectos adversos, los Inhibidores de la Enzima Convertidora de Angotensina (IECA) y Antagonistas de Receptores de la Angiotensina II (ARA II). Luego se abordan los restantes fármacos utilizados con mayor frecuencia en los distintos cuadros de naturaleza cardiovascular como los antiarrítmicos, la digoxina y los nitratos. Por último se destaca y se dan pautas elementales de farmacoterapia de algunas complicaciones frecuentes como arritmias, fiebre reumática, valvulopatías, insuficiencia cardíaca y cardiopatía isquémica.

Heparina de bajo peso molecular y embarazo. Tres pacientes con estenosis mitral pura / Low molecular weight heparin in pregnancy. Report of three cases with pure mitral stenosis

Se presentan 3 casos de mujeres portadoras de estenosis mitral pura con área valvular < 1 cm², que por falta de respuesta a tratamiento médico, se sometieron a valvuloplastía mitral percutánea (VMP) con técnica de Inoue antes de la semana 30 del embarazo. Desde su ingreso recibieron heparina de bajo peso molecular (HBPM; Enoxaparina) como profiláctico de formación de trombos intracavitarios y enfermedad embolígena sistémica secundaria, se realizó ecocardiogramas transtorácico y transesofágico (ETT y ETE) para demostrar efecividad del fármaco en evitar formación de trombos, sin causar efectos colaterales en la madre ni teratogénicos en el producto. La dosis utilizada fue de 40 mg. Subcutáneo cada 24 hs. durante 16 semanas en las tres pacientes, se repitió el ETT y ETE durante la VMP y se demostró ausencia de trombos intracavitarios. Ninguna paciente presentó alteraciones en la biometría hemática, ni en los tiempos de coagulación. Se obtuvieron productos sin malformaciones. En conclusión, aunque la serie de pacientes es pequeña, se demostró que la HBPM puede utilizarse como alternativa del uso de anticoagulante oral así como de la heparina convencional, como profiláctico durante el primer trimestre del embarazo sin provocar efectos secundarios indeseables

Esmolol en fibrilación auricular rápida secundaria a estenosis mitral / Utility of esmolol in rapid auricular flutter secondary to mitral stenoses

Se estudiaron 40 pacientes portadores de estenosis mitral, confirmada por cateterismo cardiaco y/o ecocardiografía transtorácica, programados para remplazo valvular mitral, los cuales semonitorizaron con electrocardiograma (DII), línea arterial, así comocatéter de flotación en arteria pulmonar. Registrándose las siguientes constantes hemodinámicas: Frecuencia Cardiaca (FC), presión arterial media (PAM), presión arterial pulmonar (PAP), presión capilar pulmonar (PCP), presión venosa central (PVC) y Gasto Cardiaco (GC), calculándoce Volumen Latido (VL), Indice sistólico (IS), Resistencias Vasculares Sistémicas (VS), Indice Trabajo Ventricular Izquierdo (ITVI), Resistencias Vasculares Pulmonares (RVP) y Producto presión-frecuencia (PPF). Se estímulo de ninguna índole se administró clorhidrato de esmolol en infusión a dosis de 450 µg/kg/min durante 15 min, tiempo en el cual se realizaron las mediciones antes mencionadas; básales (sin esmolol) y a los 3, 5, 10 y 15 minutos de iniciada la infusión, obteniéndose resultados significativos en el gasto cardiaco, índice cardiaco, frecuencia cardiaca, volumen latido,índice sistólico e índice de trabajo de ventricular izquierdo así como en las resistencias vasculares sistémicas y producto presión-frecuencia

Long term effects of atenolol in patients of mitral stenosis & normal sinus rhythm.

We studied the effect of atenolol 100 mg/day in 50 symptomatic patients of mitral stenosis and normal sinus rhythm, in a placebo controlled study. Atenolol caused significant bradycardia as compared to placebo (vitamin C; P < 0.001) without any adverse effects. It also increased exercise capacity significantly as compared to placebo (P < 0.001). All the patients were followed up to the period of 9 months and no adverse effects were seen. We conclude that beta adrenergic blocking drugs like atenolol can be used as the only treatment for patients with mitral stenosis without congestive heart failure and in sinus rhythm, for long-term symptomatic relief.

Safety and antithrombotic effects of fixed low-dose warfarin-aspirin combination in rheumatic mitral stenosis associated with atrial fibrillation

The incidence of thromboembolic complications in cases of mitral stenosis [MS] associated with atrial fibrillation [AF] is around 20%. To prevent this complication, warfarin and aspirin is administered to keep the INR between 2 and 3. However, this treatment is associated with increased risk of hemorrhagic episodes. Fifty-five patients with both rheumatic MS and AF, were randomly divided into two groups; Twenty-five patients received 2.5-mg of warfarin and 100 mg of aspirin daily, and thirty patients served as control. The mean +/- SD INR in the treatment group [1.58 +/- 0.45] was significantly higher than that of the control group [1.175 +/- 0.21] [p < 0.001]. Twenty per cent of the control group developed thromboembolic complications. However, none of the patients in the treatment group had any thromboembolic or hemorrhagic events. No inter - or intra-patient INR variability was seen. Therefore the use of low-dose warfarin - aspirin combination for the prevention of thromboembolic complications in patients with MS associated with AF is effective and safe, and thus, is strongly suggested

Hemodynamic effects of a beta adrenergic blocking agent-atenolol in patients with severe mitral stenosis.

The hemodynamic effects of atenolol, a cardioselective adrenergic blocking drug, were studied in 10 patients with clinically severe mitral stenosis during cardiac catheterization to evaluate the severity of disease before cardiac surgery. At 5 minutes after intravenous injection of 0.1 mg/kg of atenolol, there were significant reductions of heart rate, cardiac index, pulmonary pressure, pulmonary capillary wedge pressure and mitral valve gradient. The right and left ventricular filling pressures were increased slightly. The pulmonary and systemic vascular resistance did not change after atenolol. The PR interval although prolonged significantly was still within normal range. No serious side effects occurred during the post-catheterization 24 hour observation period except for one patient who developed slow ventricular rate (48/min) during the study. The hemodynamic effects of atenolol observed in this study appear to benefit the patients with mitral stenosis by reduction of pulmonary pressure, pulmonary capillary wedge pressure and mitral valve gradient. These hemodynamic changes may, therefore, lead to improvement of pulmonary congestive symptoms.

Evolução clínica de portadoras de estenose mitral no ciclo gravídico-puerperal / Clinical evolution of women with mitral valve stenosis during pregnancy, delivery and puerperium

Objetivo - Estudar a evoluçäo clínica de portadoras de estenose mitral no ciclo gravídico-puerperal que iniciaram a gravidez em classe funcional (CF) I/II. Métodos - Noventa e três mulheres, divididas em três grupos: Grupo GE - 30 gestantes portadoras de estenose mitral com média de idade de 27,9 anos. 26(86,7%) apresentavam sobrecarga atrial esquerda e nove (30%) ventricular direita no eletrocardiograma. A área valvar mitral ao ecodopplercardiograma variou entre 0,7 a 1,9 (1,26) cm*. Grupo GN - 32 gestantes näo cardiopatas, com média de idade de 25,5 anos com eletrocardiograma e área valvar mitral ao ecodopplercardiograma normais. Grupo EM - 31 portadoras de estenose mitral, näo grávidas com média de idade de 25 anos. Dezenove (61,3%) apresentavam sobrecarga atrial esquerda e quatro (13%) sobrecarga ventricular direita no eletrocardiograma. A área valvar mitral variou entre 0,50 a 1,80 (média = 1,19) cm*. Em cada consulta foram anotados os dados sobre CF e complicaçöes. As complicaçöes investigadas foram congestäo pulmonar, endocardite infecciosa, arritmia cardíaca e tromboembolismo. Resultados - Vinte e seis (86,7%) pacientes do grupo GE modificaram a CF: 16 evoluíram para CF III e 10 para IV, no grupo GN, 18 (56,2%) pacientes evoluíram de CF I para II no decorrer da gestaçäo e no grupo EM, cinco (16%) evoluíram da CF I/II para III durante o estudo. Arritmia cardíaca, endocardite infecciosa näo foram registradas. Fenômeno tromboembólico foi identificado em um (3,2%) caso no grupo EM. Näo houve mortalidade. Conclusäo - A grande maioria das gestantes portadoras de estenose mitral, que iniciaram a gravidez em CF I/II evoluíram para CF III/IV, no decorrer da gestaçäo. Medidas como repouso, farmacoterapia e avalvoplastia por cateter-baläo contribuíram, na totalidade dos casos, para o termo da gestaçäo e ausência de mortalidade

Purpose The clinical evolution of women with mitral stenosis was studied during pregnancy, delivery and puerperium in inicial function (FCJ class I/II. Methods ­ Ninety-three women were divided in three groups. Group GE Pregnant women with mitral stenosis (n = 30, mean age 28 years); 26 (86.7%) patients had electrocardiographic signs of left atrial enlargement and nine (30%) had signs of right ventricular hypertrophy. The mitral valvar area was between 0.7 and 1.9 (mean = 1.26) cm2 at echod opplercardiogram, Group GM Normal pregnant women (n = 32; aged 25.4 years), the electrocardiogram and echodopplercardiogram were normal. Group EM - non pregnant patients, with mitral stenosis (n = 31.33 years); 19 (61,3%) had left atrial enlargement andfour (13%) had right ventricular hypertrophy. The mitral valvar area between 0.50 and 1.80 (mean = 1.19) cm2. The variables analyzed were FC and occurrence of the following complications. infective endocarditis, cardiac arrhythmias and thromboembolism. Results In GE group, 26 (86,7%) patients worsened the FC during gestation, 16 to FC III and 10 to FC IV. In GN group, 18 (56,2% ) patients changed from FC I to FC II during the gestation and in EM group 5 (16,2%) patients changed from FC I/II to III during the study. Cardiac arrhythmias and infective endocarditis were not observed; thromboembolic event was registered in one (3.2%) patients from EM group. There were no death in all groups. Conclusion ­ The large majority of pregnant with mitral stenosis that started pregnancy in FC I/II worsened to FC III/IV during gestation. Medical treatment and eventually balloon valvuloplasty were successfull measure to allow a full-term gestation without mortality

Beta blockade for patients of mitral stenosis in sinus rhythm.

Twenty patients of isolated mitral stenosis in normal sinus rhythm (age 22 +/- 4 yrs) in whom symptoms of systemic and pulmonary congestion were controlled on diuretics were the subjects of the present study. The effects of addition of Metoprolol 50 mg po bid for 4 weeks on subjective and objective indices of exercise tolerance were evaluated. Metoprolol produced greater than 50% subjective improvement in 80% of these patients. The increase in time to dyspnoea and total work done on treadmill after 90-120 mins, and after 12 hrs of a dose of metoprolol, were both significant (p less than 0.01). In none of the patients, resting heart rate less than 50/mt, resting and exercise systolic BP less than 90 and less than 105 mmHg, respectively, or any important untoward effects were observed. Metoprolol's beneficial effects and safety can be judged in these patients at two hours after first dose in out patients clinic.