2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary
2014; Lippincott Williams & Wilkins; Volume: 129; Issue: 23 Linguagem: Inglês
10.1161/cir.0000000000000029
ISSN1524-4539
AutoresRick A. Nishimura, Catherine M Otto, Robert O. Bonow, Blasé A. Carabello, John P. Erwin, Robert A. Guyton, Patrick T. O’Gara, Carlos E. Ruiz, Nikolaos J. Skubas, Paul Sorajja, Thoralf M. Sundt, James D. Thomas,
Tópico(s)Cardiac Imaging and Diagnostics
ResumoHomeCirculationVol. 129, No. 232014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessResearch ArticlePDF/EPUB2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive SummaryA Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Rick A. Nishimura, MD, MACC, FAHA, Catherine M. Otto, MD, FACC, FAHA, Robert O. Bonow, MD, MACC, FAHA, Blase A. Carabello, MD, FACC, John P. ErwinIII, MD, FACC, FAHA, Robert A. Guyton, MD, FACC, Patrick T. O’Gara, MD, FACC, FAHA, Carlos E. Ruiz, MD, PhD, FACC, Nikolaos J. Skubas, MD, FASE, Paul Sorajja, MD, FACC, FAHA, Thoralf M. SundtIII, MD and James D. Thomas, MD, FASE, FACC, FAHA Rick A. NishimuraRick A. Nishimura †ACC/AHA representative. Search for more papers by this author , Catherine M. OttoCatherine M. Otto †ACC/AHA representative. Search for more papers by this author , Robert O. BonowRobert O. Bonow †ACC/AHA representative. Search for more papers by this author , Blase A. CarabelloBlase A. Carabello *Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. Search for more papers by this author , John P. ErwinIIIJohn P. ErwinIII ‡ACC/AHA Task Force on Performance Measures liaison. Search for more papers by this author , Robert A. GuytonRobert A. Guyton *Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. Search for more papers by this author , Patrick T. O’GaraPatrick T. O’Gara †ACC/AHA representative. Search for more papers by this author , Carlos E. RuizCarlos E. Ruiz †ACC/AHA representative. Search for more papers by this author , Nikolaos J. SkubasNikolaos J. Skubas ¶Society of Cardiovascular Anesthesiologists representative. Search for more papers by this author , Paul SorajjaPaul Sorajja #Society for Cardiovascular Angiography and Interventions representative. Search for more papers by this author , Thoralf M. SundtIIIThoralf M. SundtIII *Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. Search for more papers by this author and James D. ThomasJames D. Thomas ‡‡American Society of Echocardiography representative. Search for more papers by this author Originally published3 Mar 2014https://doi.org/10.1161/CIR.0000000000000029Circulation. 2014;129:2440–2492is corrected byCorrectionOther version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2014: Previous Version 1 IntroductionTable of ContentsPreamble 2441Introduction 24441.1. Methodology and Evidence Review 24441.2. Organization of the Writing Committee 24441.3. Document Review and Approval 24441.4. Scope of the Guideline 2444General Principles 24442.1. Evaluation of the Patient With Suspected VHD 24442.2. Definitions of Severity of Valve Disease 24452.3. Diagnostic Testing–Diagnosis and Follow-Up: Recommendations 24452.4. Basic Principles of Medical Therapy: Recommendations 24462.5. Evaluation of Surgical and Interventional Risk 24462.6. The Heart Valve Team and Heart Valve Centers of Excellence: Recommendations 2446Aortic Stenosis: Recommendations 24473.1. Stages of Valvular AS 24483.2. Diagnosis and Follow-Up 24493.3. Medical Therapy 24503.4. Timing of Intervention 24503.5. Choice of Intervention 2451Aortic Regurgitation: Recommendations 24524.1. Stages of Chronic Aortic Regurgitation 24524.2. Diagnosis and Follow-Up 24524.3. Medical Therapy 24524.4. Timing of Intervention 2452Bicuspid Aortic Valve and Aortopathy: Recommendations 24545.1. Diagnosis and Follow-Up 24545.2. Intervention 2454Mitral Stenosis: Recommendations 24556.1. Stages of MS 24556.2. Diagnosis and Follow-Up 24556.3. Medical Therapy 24556.4. Intervention 2456Mitral Regurgitation: Recommendations 24577.1. Stages of Chronic MR 24577.2. Chronic Primary MR 24587.2.1. Diagnosis and Follow-Up 24587.2.2. Medical Therapy 24587.2.3. Intervention 24597.3. Chronic Secondary MR 24617.3.1. Diagnosis and Follow-Up 24617.3.2. Medical Therapy 24617.3.3. Intervention 2461Tricuspid Valve Disease: Recommendations 24618.1. Stages of TR 24618.2. Tricuspid Regurgitation 24618.2.1. Diagnosis and Follow-Up 24618.2.2. Medical Therapy 24628.2.3. Intervention 24628.3. Stages of Tricuspid Stenosis 24638.4. Tricuspid Stenosis 24638.4.1. Diagnosis and Follow-Up 24638.4.2. Intervention 2463Stages of Pulmonic Valve Disease 2463Prosthetic Valves: Recommendations 246310.1. Evaluation and Selection of Prosthetic Valves 246310.1.1. Diagnosis and Follow-Up 246310.1.2. Intervention 246310.2. Antithrombotic Therapy for Prosthetic Valves 246410.3. Bridging Therapy for Prosthetic Valves 246610.4. Excessive Anticoagulation and Serious Bleeding With Prosthetic Valves 246610.5. Prosthetic Valve Thrombosis 246610.5.1. Diagnosis and Follow-Up 246610.5.2. Medical Therapy 246710.5.3. Intervention 246710.6. Prosthetic Valve Stenosis 246710.7. Prosthetic Valve Regurgitation 2467Infective Endocarditis: Recommendations 246711.1. Diagnosis and Follow-Up 246711.2. Medical Therapy 246911.3. Intervention 2469Pregnancy and VHD: Recommendations 247112.1. Native Valve Stenosis 247112.1.1. Diagnosis and Follow-Up 247112.1.2. Medical Therapy 247112.1.3. Intervention 247212.2. Native Valve Regurgitation 247312.2.1. Diagnosis and Follow-Up 247312.2.2. Medical Therapy 247312.2.3. Intervention 247312.3. Prosthetic Valves in Pregnancy 247412.3.1. Diagnosis and Follow-Up 247412.3.2. Medical Therapy 2475Surgical Considerations: Recommendations 247513.1. Evaluation of Coronary Anatomy 247513.2. Concomitant Procedures 247513.2.1. Intervention for CAD 247513.2.2. Intervention for AF 2475Noncardiac Surgery in Patients With VHD: Recommendations 2476References 2476Appendix 1. Author Relationships With Industry and Other Entities (Relevant) 2486Appendix 2. Reviewer Relationships With Industry and Other Entities (Relevant) 2488PreambleThe medical profession should play a central role in evaluating evidence related to drugs, devices, and procedures for detection, management, and prevention of disease. When properly applied, expert analysis of available data on the benefits and risks of these therapies and procedures can improve the quality of care, optimize patient outcomes, and favorably affect costs by focusing resources on the most effective strategies. An organized and directed approach to a thorough review of evidence has resulted in the production of clinical practice guidelines that assist clinicians in selecting the best management strategy for an individual patient. Moreover, clinical practice guidelines can provide a foundation for other applications, such as performance measures, appropriate use criteria, and both quality improvement and clinical decision support tools.The American College of Cardiology (ACC) and the American Heart Association (AHA) have jointly engaged in the production of guidelines in the area of cardiovascular disease since 1980. The ACC/AHA Task Force on Practice Guidelines (Task Force) directs this effort by developing, updating, and revising practice guidelines for cardiovascular diseases and procedures.Experts in the subject under consideration are selected from both ACC and AHA to examine subject-specific data and write guidelines. Writing committees are specifically charged with performing a literature review; weighing the strength of evidence for or against particular tests, treatments, or procedures; and including estimates of expected health outcomes where such data exist. Patient-specific modifiers, comorbidities, and issues of patient preference that may influence the choice of tests or therapies are considered, as well as frequency of follow-up and cost effectiveness. When available, information from studies on cost is considered; however, a review of data on efficacy and outcomes constitutes the primary basis for preparing recommendations in this guideline.In analyzing the data and developing recommendations and supporting text, the writing committee uses evidence-based methodologies developed by the Task Force.1 The Class of Recommendation (COR) is an estimate of the size of the treatment effect, with consideration given to risks versus benefits, as well as evidence and/or agreement that a given treatment or procedure is or is not useful/effective or in some situations may cause harm. The Level of Evidence (LOE) is an estimate of the certainty or precision of the treatment effect. The writing committee reviews and ranks evidence supporting each recommendation, with the weight of evidence ranked as LOE A, B, or C, according to specific definitions. The schema for the COR and LOE is summarized in Table 1, which also provides suggested phrases for writing recommendations within each COR. Studies are identified as observational, retrospective, prospective, or randomized, as appropriate. For certain conditions for which inadequate data are available, recommendations are based on expert consensus and clinical experience and are ranked as LOE C. When recommendations at LOE C are supported by historical clinical data, appropriate references (including clinical reviews) are cited if available. For issues with sparse available data, a survey of current practice among the clinician members of the writing committee is the basis for LOE C recommendations and no references are cited.Table 1. Applying Classification of Recommendations and Level of EvidenceTable 1. Applying Classification of Recommendations and Level of EvidenceA new addition to this methodology is separation of the Class III recommendations to delineate whether the recommendation is determined to be of “no benefit” or is associated with “harm” to the patient. In addition, in view of the increasing number of comparative effectiveness studies, comparator verbs and suggested phrases for writing recommendations for the comparative effectiveness of one treatment or strategy versus another are included for COR I and IIa, LOE A or B only.In view of the advances in medical therapy across the spectrum of cardiovascular diseases, the Task Force has designated the term guideline-directed medical therapy (GDMT) to represent optimal medical therapy as defined by ACC/AHA guideline (primarily Class I)-recommended therapies. This new term, GDMT, is used herein and throughout subsequent guidelines.Because the ACC/AHA practice guidelines address patient populations (and clinicians) residing in North America, drugs that are not currently available in North America are discussed in the text without a specific COR. For studies performed in large numbers of subjects outside North America, each writing committee reviews the potential impact of different practice patterns and patient populations on the treatment effect and relevance to the ACC/AHA target population to determine whether the findings should inform a specific recommendation.The ACC/AHA practice guidelines are intended to assist clinicians in clinical decision making by describing a range of generally acceptable approaches to the diagnosis, management, and prevention of specific diseases or conditions. The guidelines attempt to define practices that meet the needs of most patients in most circumstances. The ultimate judgment about care of a particular patient must be made by the clinician and patient in light of all the circumstances presented by that patient. As a result, situations may arise in which deviations from these guidelines may be appropriate. Clinical decision making should involve consideration of the quality and availability of expertise in the area where care is provided. When these guidelines are used as the basis for regulatory or payer decisions, the goal should be improvement in quality of care. The Task Force recognizes that situations arise in which additional data are needed to inform patient care more effectively; these areas are identified within each respective guideline when appropriate.Prescribed courses of treatment in accordance with these recommendations are effective only if followed. Because lack of patient understanding and adherence may adversely affect outcomes, clinicians should make every effort to engage the patient's active participation in prescribed medical regimens and lifestyles. In addition, patients should be informed of the risks, benefits, and alternatives to a particular treatment and should be involved in shared decision making whenever feasible, particularly for COR IIa and IIb, for which the benefit-to-risk ratio may be lower.The Task Force makes every effort to avoid actual, potential, or perceived conflicts of interest that may arise as a result of relationships with industry and other entities (RWI) among the members of the writing committee. All writing committee members and peer reviewers of the guideline are required to disclose all current healthcare-related relationships, including those existing 12 months before initiation of the writing effort.In December 2009, the ACC and AHA implemented a new RWI policy that requires the writing committee chair plus a minimum of 50% of the writing committee to have no relevant RWI (Appendix 1 includes the ACC/AHA definition of relevance). The Task Force and all writing committee members review their respective RWI disclosures during each conference call and/or meeting of the writing committee, and members provide updates to their RWI as changes occur. All guideline recommendations require a confidential vote by the writing committee and require approval by a consensus of the voting members. Authors' and peer reviewers' RWI pertinent to this guideline are disclosed in Appendixes 1 and 2. Members may not draft or vote on any recommendations pertaining to their RWI. Members who recused themselves from voting are indicated in the list of writing committee members with specific section recusals noted in Appendix 1. In addition, to ensure complete transparency, writing committee members' comprehensive disclosure information—including RWI not pertinent to this document—is available as an online supplement.Comprehensive disclosure information for the Task Force is also available online at http://www.cardiosource.org/en/ACC/About-ACC/Who-We-Are/Leadership/Guidelines-and-Documents-Task-Forces.aspx. The ACC and AHA exclusively sponsor the work of the writing committee without commercial support. Writing committee members volunteered their time for this activity. Guidelines are official policy of both the ACC and AHA.In an effort to maintain relevance at the point of care for clinicians, the Task Force continues to oversee an ongoing process improvement initiative. As a result, several changes to these guidelines will be apparent, including limited narrative text, a focus on summary and evidence tables (with references linked to abstracts in PubMed), and more liberal use of summary recommendation tables (with references that support LOE) to serve as a quick reference.In April 2011, the Institute of Medicine released 2 reports: Finding What Works in Health Care: Standards for Systematic Reviews and Clinical Practice Guidelines We Can Trust.2,3 It is noteworthy that the Institute of Medicine cited ACC/AHA practice guidelines as being compliant with many of the proposed standards. A thorough review of these reports and of our current methodology is under way, with further enhancements anticipated.The recommendations in this guideline are considered current until they are superseded by a focused update, the full-text guideline is revised, or until a published addendum declares it out of date and no longer official ACC/AHA policy. The reader is encouraged to consult the full-text guideline4 for additional guidance and details about valvular heart disease (VHD), since the executive summary contains only the recommendations.Jeffrey L. Anderson, MD, FACC, FAHAChair, ACC/AHA Task Force on Practice Guidelines1. Introduction1.1. Methodology and Evidence ReviewThe recommendations listed in this document are, whenever possible, evidence based. An extensive review was conducted on literature published through November 2012, and other selected references through October 2013 were reviewed by the guideline writing committee. The relevant data are included in evidence tables in the Data Supplement. Searches were extended to studies, reviews, and other evidence conducted on human subjects and that were published in English from PubMed, EMBASE, Cochrane, Agency for Healthcare Research and Quality Reports, and other selected databases relevant to this guideline. Key search words included but were not limited to the following: valvular heart disease, aortic stenosis, aortic regurgitation, bicuspid aortic valve, mitral stenosis, mitral regurgitation, tricuspid stenosis, tricuspid regurgitation, pulmonic stenosis, pulmonic regurgitation, prosthetic valves, anticoagulation therapy, infective endocarditis, cardiac surgery, and transcatheter aortic valve replacement. Additionally, the committee reviewed documents related to the subject matter previously published by the ACC and AHA. The references selected and published in this document are representative and not all-inclusive.1.2. Organization of the Writing CommitteeThe committee was composed of clinicians, who included cardiologists, interventionalists, surgeons, and anesthesiologists. The committee included representatives from the American Association for Thoracic Surgery, American Society of Echocardiography (ASE), Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons (STS).1.3. Document Review and ApprovalThis document was reviewed by 2 official reviewers each nominated by both the ACC and the AHA, as well as 1 reviewer each from the American Association for Thoracic Surgery, ASE, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Anesthesiologists, and STS and 39 individual content reviewers (which included representatives from the following ACC committees and councils: Adult Congenital and Pediatric Cardiology Section, Association of International Governors, Council on Clinical Practice, Cardiovascular Section Leadership Council, Geriatric Cardiology Section Leadership Council, Heart Failure and Transplant Council, Interventional Council, Lifelong Learning Oversight Committee, Prevention of Cardiovascular Disease Committee, and Surgeon Council). Reviewers' RWI information was distributed to the writing committee and is published in this document (Appendix 2).This document was approved for publication by the governing bodies of the ACC and the AHA and endorsed by the American Association for Thoracic Surgery, ASE, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Anesthesiologists, and STS.1.4. Scope of the GuidelineThe focus of this guideline is the diagnosis and management of adult patients with valvular heart disease (VHD). A full revision of the original 1998 VHD guideline was made in 2006, and an update was made in 2008.5 Some recommendations from the earlier VHD guidelines have been updated as warranted by new evidence or a better understanding of earlier evidence, whereas others that were inaccurate, irrelevant, or overlapping were deleted or modified. Throughout, our goal was to provide the clinician with concise, evidence-based, contemporary recommendations and the supporting documentation to encourage their use.The full-text version of this guideline4 was created in a different format from prior VHD guidelines to facilitate access to concise, relevant bytes of information at the point of care when clinical knowledge is needed the most. Thus, each COR is followed by a brief paragraph of supporting text and references. Where applicable, sections were divided into subsections of 1) diagnosis and follow-up, 2) medical therapy, and 3) intervention. The purpose of these subsections was to categorize the COR according to the clinical decision-making pathways that caregivers use in the management of patients with VHD. New recommendations for assessment of the severity of valve lesions have been proposed, based on current natural history studies of patients with VHD. The relevant data are included in evidence tables in the Data Supplement of the full-text guideline.4The present document applies to adult patients with VHD. Management of patients with congenital heart disease (CHD) and infants and children with valve disease are not addressed here. The document recommends a combination of lifestyle modifications and medications that constitute GDMT. Both for GDMT and other recommended drug treatment regimens, the reader is advised to confirm dosages with product insert material and to carefully evaluate for contraindications and drug–drug interactions. Table 2 is a list of associated guidelines that may be of interest to the reader. The table is intended for use as a resource and obviates the need to repeat extant guideline recommendations.Table 2. Associated Guidelines and StatementsTitleOrganizationPublication Year/ReferenceRecommendations for Evaluation of the Severity of Native Valvular Regurgitation With Two-Dimensional and Doppler EchocardiographyASE20036Guidelines for the Management of Adults With Congenital Heart DiseaseACC/AHA20088Echocardiographic Assessment of Valve Stenosis: EAE/ASE Recommendations for Clinical PracticeEAE/ASE20099Recommendations for Evaluation of Prosthetic Valves With Echocardiography and Doppler UltrasoundASE200910Guideline for the Diagnosis and Treatment of Hypertrophic CardiomyopathyACCF/AHA201111Guidelines on the Management of Cardiovascular Diseases During PregnancyESC201112Antithrombotic and Thrombolytic Therapy for Valvular Disease: Antithrombotic Therapy and Prevention of ThrombosisACCP201213Guidelines on the Management of Valvular Heart DiseaseESC/EACTS201214Guideline for th0e Management of Heart FailureACCF/AHA201315Guideline for the Management of Patients With Atrial FibrillationAHA/ACC/HRS201416ACC indicates American College of Cardiology; ACCF, American College of Cardiology Foundation; ACCP, American College of Chest Physicians; AF, atrial fibrillation; AHA, American Heart Association; ASE, American Society of Echocardiography; EACTS, European Association for Cardio-Thoracic Surgery; EAE, European Association of Echocardiography; ESC, European Society of Cardiology; and VHD, valvular heart disease.2. General Principles2.1. Evaluation of the Patient With Suspected VHDPatients with VHD may present with a heart murmur, symptoms, or incidental findings of valvular abnormalities on chest imaging or noninvasive testing. Irrespective of the presentation, all patients with known or suspected VHD should undergo an initial meticulous history and physical examination, as well as a chest x-ray and electrocardiogram. A comprehensive transthoracic echocardiogram (TTE) with 2-dimensional imaging and Doppler interrogation should then be performed to correlate findings with initial impressions based on the initial clinical evaluation. The TTE will also be able to provide additional information, such as the effect of the valve lesion on the cardiac chambers and great vessels, and to assess for other concomitant valve lesions. Other ancillary testing such as transesophageal echocardiography (TEE), computed tomography (CT) or cardiac magnetic resonance (CMR) imaging, stress testing, and diagnostic hemodynamic cardiac catheterization may be required to determine the optimal treatment for a patient with VHD. An evaluation of the possible surgical risk for each individual patient should be performed if intervention is contemplated, as well as other contributing factors such as the presence and extent of comorbidities and frailty. Follow-up of these patients is important and should consist of an annual history and physical examination in most stable patients. An evaluation of the patient may be necessary sooner than annually if there is a change in the patient's symptoms. In some valve lesions there may be unpredictable adverse consequences on the left ventricle in the absence of symptoms necessitating more frequent follow-up. The frequency of repeat testing, such as echocardiography, will be dependent on the severity of the valve lesion and its effect on the left or right ventricle, coupled with the known natural history of the valve lesion.2.2. Definitions of Severity of Valve DiseaseClassification of the severity of valve lesions should be based on multiple criteria, including the initial findings on the physical examination, which should then be correlated with data from a comprehensive TTE. Intervention should primarily be performed on patients with severe VHD in addition to other criteria outlined in this document.This document provides a classification of the progression of VHD with 4 stages (A to D) similar to that proposed by the “2013 ACCF/AHA Guideline for the Management of Heart Failure.”18 Indication for intervention in patients with VHD is dependent on 1) the presence or absence of symptoms; 2) the severity of VHD; 3) the response of the left and/or right ventricle to the volume or pressure overload caused by VHD; 4) the effect on the pulmonary or systemic circulation; and 5) a change in heart rhythm. The stages take into consideration all of these important factors (Table 3). The criteria for the stages of each individual valve lesion are listed in Section 3.1, Section 4.1, Section 6.1, Section 7.1, Section 8.1, Section 8.3, and Section 9.Table 3. Stages of Progression of VHDStageDefinitionDescriptionAAt riskPatients with risk factors for development of VHDBProgressivePatients with progressive VHD (mild-to-moderate severity and asymptomatic)CAsymptomatic severeAsymptomatic patients who have the criteria for severe VHD:C1: Asymptomatic patients with severe VHD in whom the left or right ventricle remains compensatedC2: Asymptomatic patients with severe VHD, with decompensation of the left or right ventricleDSymptomatic severePatients who have developed symptoms as a result of VHDVHD indicates valvular heart disease.The purpose of valvular intervention is to improve symptoms and/or prolong survival, as well as to minimize the risk of VHD-related complications such as asymptomatic irreversible ventricular dysfunction, pulmonary hypertension, stroke, and atrial fibrillation (AF). Thus, the criteria for “severe” VHD are based on studies describing the natural history of patients with unoperated VHD, as well as observational studies relating the onset of symptoms to measurements of severity. In patients with stenotic lesions, there is an additional category of “very severe” stenosis based on studies of the natural history showing that prognosis becomes poorer as the severity of stenosis increases.2.3. Diagnostic Testing—Diagnosis and Follow-Up: RecommendationsSee Table 4 for the frequency of echocardiograms in asymptomatic patients with VHD and normal left ventricular (LV) function.Table 4. Frequency of Echocardiograms in Asymptomatic Patients With VHD and Normal Left Ventricular FunctionStageValve LesionStageAortic Stenosis*Aortic RegurgitationMitral StenosisMitral RegurgitationProgressive (stage B)Every 3–5 y(mild severity Vmax.20–2.9 m/s)Every 3–5 y (mild severity)Every 1–2 y (moderate severity)Every 3–5 y(MVA >1.5 cm2)Every 3–5 y (mild severity)Every 1–2 y (moderate severity)Every 1–2 y(moderate severity Vmax.30–3.9 m/s)Severe(stage C)Every 6–12 mo(Vmax ≥4 m/s)Every 6–12 moDilating LV: more frequentlyEvery 1–2 y(MVA.10–1.5 cm2)Once every year(MVA <1.0 cm2)Every 6–12 moDilating LV: more frequentlyPatients with mixed valve disease may require serial evaluations at intervals earlier than recommended for single valve lesions.*With normal stroke volume.LV indicates left ventricle; MVA, mitral valve area; VHD, valvular heart disease; and Vmax, maximum velocity.Class ITTE is recommended in the initial evaluation of patients with known or suspected VHD to confirm the diagnosis, establish etiology, determine severity, assess hemodynamic consequences, determine prognosis, and evaluate for timing of intervention.19–34(Level of Evidence: B)TTE is recommended in patients with known VHD with any change in symptoms or physical examination findings. (Level of Evidence: C)Periodic monitoring with TTE is recommended in asymptomatic patients with known VHD at intervals depending on valve lesion, severity, ventricular size, and ventricular function. (Level of Evidence: C)Cardiac catheterization for hemodynamic assessment is recommended in symptomatic patients when noninvasive tests are inconclusive or when there is a discrepancy between the findings on noninvasive testing and physical examination regarding severity of the valve lesion. (Level of Evidence: C)Class IIaExercise testing is reasonable in selected patients with asymptomatic severe VHD to 1) confirm the absence of symptoms, or 2) assess the hemodynamic response to exercise, or 3) determine prognosis.35–39(Level of Evidence: B)2.4. Basic Principles of Medical Therapy: RecommendationsClass ISecondary prevention of rheumatic fever is indicated in patients with rheumatic heart disease, specifically mitral stenosis (MS).40 (Level of Evidence: C)Class IIaProphylaxis against infective endocarditis (IE) is reasonab
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