Some possible adverse reactions of SSRIs include headache, gastrointestinal side effects, dry mouth, sedation or insomnia and activation. Activation refers to a state of psychomotor agitation that includes symptoms of insomnia, disinhibition and restlessness that may result in discontinuation of a medication. There is a rare risk of suicidal thoughts or behaviors with SSRIs especially when treatment is started or the dose is increased, with the rate being up to 0.7% as compared to placebo in early meta analyses of SSRIs in the treatment of adolescent depression. This led the FDA to issue a black box warning regarding this risk. Once remission is achieved, the medications are continued for at least 6 to 12 months and then there is consideration of discontinuing them. Early or premature discontinuation of medications, prior to 6 to 12 months of having achieved remission, is associated with an increased risk of relapse of the depression.The combination of psychotherapy with medications has been shown to be more effective for the treatment of depression in adolescence than medications alone.Other medications can be added to SSRIs if a partial response is achieved and further improvement is needed; these agents include lithium, bupropion and atypical antipsychotics. These options are medications that work in different ways. Bupropion (Wellbutrin) works through the neurotransmitters norepinephrine and dopamine, while mirtazapine (Remeron) affects transmission of norepinephrine and serotonin. The drugs venlafaxine (Effexor) and duloxetine (Cymbalta) work in part by simultaneously inhibiting the reuptake of serotonin and norepinephrine.
The frontal plane QRS is the most helpful clue to distinguish between an ostium secundum ASD and an ostium primum ASD. In primum defects left axis deviation is seen in most patients with an axis of > -30 degrees and very few patients have right axis deviation. In contrast ostium secundum defects have an axis between 0 degrees and 180 degrees with most cases to the right of 100 degrees.In the ECG above, you can see an example of the rSR pattern in V1 with a R greater than S with T wave inversion which is commonly seen in volume overload right ventricular hypertrophy. Diagnosis
Classification
A defect in the ostium primum is occasionally classified as an atrial septal defect, but it is more commonly classified as an atrioventricular septal defect. Treatment
Hemodynamically significant ASDs (flow ratio 1.5:1) are large enough to be closed surgically. The long term prognosis is excellent. Pulmonary hypertension with shunt reversal is a contraindication for surgery, however the pulmonary hypertension can frequently be treated with medicines. The hole can then be closed safely with a good long term prognosis. References
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