From the Guidelines
Neurohormone-modifying agents such as angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, β-blockers, and mineralocorticoid receptor antagonists are used to decrease afterload, to improve pump function, and to potentially contribute to ventricular recovery in patients with Ventricular Assist Devices (VAD). When managing VAD patients, it is crucial to consider the potential for hypertension and hypotension, as both can have significant impacts on morbidity, mortality, and quality of life 1. Key considerations in VAD management include:
- Maintaining a mean arterial blood pressure in the normal range to optimize forward flow and prevent adverse events
- Using diuretics to manage symptoms of right ventricular (RV) failure and fluid retention
- Considering the use of hydralazine/nitrates and phosphodiesterase type 5 inhibitors such as sildenafil and tadalafil for RV failure and pulmonary hypertension 1. In clinical practice, the choice of medication for VAD patients should prioritize minimizing the risk of neurological events and end-organ damage, while also optimizing pump function and potentially contributing to ventricular recovery. The use of neurohormone-modifying agents, as recommended in the 2017 American Heart Association scientific statement 1, is a key component of this approach.
From the Research
Medication for VAD
- The most commonly used medication for VAD is aspirin, which is often used as a lifelong administration after VAD implantation 2.
- Antiplatelet drugs, such as aspirin, play a key role in preventing VAD thrombosis, and anticoagulant drugs are also recommended, although with varying efficacy targets 2.
- Dual antiplatelet therapy, which targets multiple pathways of platelet activation, may be used for patients who develop thrombotic events despite an increased risk of bleeding complications 2.
- Warfarin is also used as an anticoagulant therapy to reduce the risk of thrombotic events in VAD patients, and the quality of anticoagulation can be assessed by the time in therapeutic range (TTR) 3.
- The combination of warfarin and aspirin versus warfarin alone has been compared in some studies, with no significant difference found in the risk of bleeding or thrombotic events 4.
Anticoagulation and Antiplatelet Strategies
- Anticoagulation and antiplatelet strategies are crucial in VAD management, and a thorough understanding of device, patient, and management factors is necessary to optimize outcomes 5.
- The pathophysiology of bleeding and thrombotic complications in VAD patients is complex, and different strategies have been attempted to manage these complications, including the use of novel oral anticoagulants and artificial heart valves 5.
- The management of heparin-induced thrombocytopenia, anticoagulant reversal, and noncardiac surgeries are also important considerations in VAD patients 5.