From the Guidelines
The treatment plan for adults with congenital heart disease and systemic right ventricle (RV) dysfunction should prioritize a comprehensive individual assessment, considering health habits, cardiovascular risk factors, multimorbidity, physical/cognitive status, life expectancy, time to benefit or harm, and goals of care 1. When managing patients with systemic RV dysfunction, it is essential to consider the potential risks and benefits of medical therapy, as the current evidence is largely uncertain 1.
- The use of angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, beta blockers, or aldosterone antagonists alone or in combination has not been shown to improve outcomes in patients with systemic RV dysfunction 1.
- However, in symptomatic patients or those with larger and/or more dysfunctional right ventricles, there may be a potential benefit to medical therapy, although this is speculative and requires further research 1.
- The decision to implant an implantable cardioverter-defibrillator (ICD) for primary prevention of arrhythmia in patients with low systemic ventricular ejection fraction should be made on a case-by-case basis, taking into account the patient's full clinical presentation and in consultation with cardiac electrophysiologists with expertise in adult congenital heart disease 1.
- A comprehensive geriatric assessment should be performed to identify potential age-related changes in cardiovascular structure and function, as well as pharmacokinetics/pharmacodynamics, to minimize the risk of adverse drug reactions and optimize pharmacotherapy 1.
- The treatment plan should prioritize the preservation of functional independence and quality of life, alleviation of distressing symptoms, and consideration of the time to benefit or harm of therapy, rather than solely focusing on prolonging survival 1.
From the Research
Treatment Plan for Atrial Fibrillation with Rivaroxaban
- Rivaroxaban is a direct factor Xa inhibitor used for the prevention of stroke and systemic embolism in patients with nonvalvular atrial fibrillation 2.
- The dose and frequency of administration of rivaroxaban vary depending on the indication, and it is administered without routine coagulation testing due to its predictable pharmacokinetics and pharmacodynamics 2.
- Rivaroxaban has a lower potential for drug interactions compared to warfarin, but health systems need to perform a systematic safety evaluation and update hospital policies related to anticoagulation to include rivaroxaban 2.
Efficacy and Safety of Rivaroxaban
- Rivaroxaban has been shown to be effective in the treatment of deep vein thrombosis and pulmonary embolism, with a lower rate of major bleeding compared to standard therapy consisting of enoxaparin and vitamin K antagonist 3.
- Rivaroxaban has also been shown to be effective in the prevention of recurrent venous thromboembolism, with a significant reduction in the incidence of symptomatic recurrent venous thromboembolism compared to placebo 3.
- However, rivaroxaban has been associated with an increased risk of major ischemic or hemorrhagic events compared to apixaban in patients with atrial fibrillation 4.
Comparison with Other Anticoagulants
- Rivaroxaban has been compared to warfarin in the management of unusual site deep vein thrombosis, and has been shown to have comparable efficacy with a lower risk of bleeding complications and major bleeding 5.
- Rivaroxaban has also been compared to apixaban in patients with atrial fibrillation, and has been shown to have an increased risk of major ischemic or hemorrhagic events 4.