Mitral stenosis medical therapy

Jump to: navigation, search

Mitral Stenosis Microchapters

Home

Patient Information

Overview

Pathophysiology

Causes

Differentiating Mitral Stenosis from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

Stages

History and Symptoms

Physical Examination

Electrocardiogram

Chest X Ray

Echocardiography

Cardiac MRI

Cardiac Catheterization

Treatment

Overview

Medical Therapy

Percutaneous Mitral Balloon Commissurotomy (PMBC)

Surgery

Follow Up

Prevention

Case Studies

Case #1

Mitral stenosis medical therapy On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

American Roentgen Ray Society Images of Mitral stenosis medical therapy

All Images
X-rays
Echo & Ultrasound
CT Images
MRI

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA onMitral stenosis medical therapy

CDC on Mitral stenosis medical therapy

Mitral stenosis medical therapy in the news

Blogs on Mitral stenosis medical therapy

Directions to Hospitals Treating Mitral Stenosis

Risk calculators and risk factors for Mitral stenosis medical therapy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Mohammed A. Sbeih, M.D.[2]; Cafer Zorkun, M.D., Ph.D. [3]; Rim Halaby, M.D. [4]

Overview

Medical therapy for mitral stenosis includes anticoagulation and rate control in patients with atrial fibrillation. Medical therapy can relieve symptoms, but the patient may need surgery to relieve the blood flow obstruction by mitral stenosis. Surgical treatment in the symptomatic patient reduces the mortality rate of mitral stenosis compared to medical treatment. The interventional and surgical treatments for mitral stenosis include: percutaneous mitral balloon valvotomy (PMBV), closed commissurotomy, open commissurotomy (valve repair), and mitral valve replacement.

Medical Therapy

Treatment of Acute Decompensation

Digoxin

Digitalis may be used among patients with AS and symptomatic right ventricular or left ventricular dysfunction, and in those with atrial fibrillation. Digitalis increases myocardial contractility and slows the ventricular response in patients with atrial arrhythmias. Slowing the heart rate prolongs the diastolic filling time and allows better filling of the left ventricle.[1][2][3][4]

Diuretics

Diuretics may be used to remove excess fluid in the lungs in patients with pulmonary edema.[5]

Low Sodium Diet

A low-sodium diet may be helpful.

Activity Restriction

Once a a patient develops symptoms, activity may be restricted.

Systemic Embolization Prevention

Anticoagulation therapy is indicated for thromboembolic events prevention among AS patients in any of the following conditions (Class I, Level of Evidence B):[6]

Rate Control

Rate control with either beta blockers or calcium channel blocker is indicated in MS in the following conditions:[6]

Secondary Prevention of Rheumatic Fever

Indications

Shown below is the table depicting the indication for secondary prophylaxis of rheumatic fever.[7]

Indications Duration of prophylaxis
Rheumatic fever with carditis and persistent valvular heart disease 10 years or until the patient is 40 years (whichever is longer) (Class I, Level of Evidence C)
Rheumatic fever with carditis but no valvular heart disease 10 years or until the patient is 21 years (whichever is longer) (Class I, Level of Evidence C)
Rheumatic fever without carditis 5 years or until the patient is 21 years (whichever is longer) (Class I, Level of Evidence C)

Antibiotic Regimens

Shown below is the table depicting the antibiotic regimens for secondary prophylaxis of rheumatic fever.[7]

Antibiotics Dosage
Penicillin G benzathine
(Class I, Level of Evidence A)
Weight >27 Kg (60 lb): 1.2 million units IM every day for 4 weeks
Weight ≤27 Kg (60 lb): 600,000 units IM every day for 4 weeks
Penicillin V
(Class I, Level of Evidence B)
200 mg orally twice a day
Sulfadiazine
(Class I, Level of Evidence B)
Weight >27 Kg (60 lb): 1 g orally once a day
Weight ≤27 Kg (60 lb): o.5 g orally once a day
Macrolide or azalide antibiotics (in patients allergic to penicillin)
(Class I, Level of Evidence C)
Varies

Prevention of Endocarditis

Endocarditis prophylaxis is not indicated among patients with MS.[8][9]

2014_2017 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary (DO NOT EDIT)[6]

Medical Therapy (DO NOT EDIT)

Class I
"1. Anticoagulation (vitamin K antagonist or heparin) is indicated in patients with:
Class IIa
"1. Heart rate control can be beneficial in patients with MS and AF and fast ventricular response. (Level of Evidence: C) "
Class IIb
"1. Heart rate control may be considered for patients with MS in normal sinus rhythm and symptoms associated with exercise. (Level of Evidence: B) "

Basic Principles of Medical Therapy (DO NOT EDIT)

Class I
"1. Secondary prevention of rheumatic fever is indicated in patients with rheumatic heart disease, specifically mitral stenosis (MS). (Level of Evidence: C) "

2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease (DO NOT EDIT)[10]

Systemic Embolization Prevention (DO NOT EDIT)[10][11]

Class I
"1. Anticoagulation is indicated in patients with mitral stenosis and atrial fibrillation (paroxysmal, persistent, or permanent). (Level of Evidence: B) "
"2. Anticoagulation is indicated in patients with mitral stenosis and a prior embolic event, even in sinus rhythm. (Level of Evidence: B) "
"3. Anticoagulation is indicated in patients with mitral stenosis with left atrial thrombus. (Level of Evidence: B) "
Class IIb
"1. Anticoagulation may be considered for asymptomatic patients with severe mitral stenosis and left atrial dimension greater than or equal to 55 mm by echocardiography.* (Level of Evidence: B) "
"2. Anticoagulation may be considered for patients with severe mitral stenosis, an enlarged left atrium, and spontaneous contrast on echocardiography. (Level of Evidence: C) "


2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease[12]

Recommendations forAnticoagulation forAtrial Fibrillation (AF) in PatientsWith VHD
LOE Recommendation Comment/Rationate
I B-NR "Anticoagulation with a vitamin K antagonist (VKA) is indicatedfor patients with rheumatic mitral stenosis (MS) and AF".[13][14] MODIFIED: "VKA as opposed to the direct oral anticoagulants (DOACs) are indicated in patients with AF and rheumatic MS to prevent thromboembolic events. The RCTs of DOACs versus VKA have not included patients with MS. The specific recommendation for anticoagulation of patients with MS is contained in a subsection of the topic on anticoagulation".[15]
"A retrospective analysis of administrative claims databases (>20,000 DOAC-treated patients) showed no difference in the incidence of stroke or major bleeding in patients with rheumatic and nonrheumatic MS if treated with DOAC versus warfarin. However, the writing group continues to recommend the use of VKA for patients with rheumatic MS until further evidence emerges on the efficacy of DOAC in this population".[16]

References

  1. ROWE JC, BLAND EF, SPRAGUE HB, WHITE PD (1960). "The course of mitral stenosis without surgery: ten- and twenty-year perspectives". Ann Intern Med. 52: 741–9. PMID 14439687.
  2. Dahl JC, Winchell P, Borden CW (1967). "Mitral stenosis. A long term postoperative follow-up". Arch Intern Med. 119 (1): 92–7. PMID 6015840.
  3. Roy SB, Gopinath N (1968). "Mitral stenosis". Circulation. 38 (1 Suppl): 68–76. PMID 4889600.
  4. Boon NA, Bloomfield P (2002). "The medical management of valvar heart disease". Heart. 87 (4): 395–400. PMC 1767079. PMID 11907022.
  5. El Sabbagh, Abdallah; Reddy, Yogesh N. V.; Barros‐Gomes, Sergio; Borlaug, Barry A.; Miranda, William R.; Pislaru, Sorin V.; Nishimura, Rick A.; Pellikka, Patricia A. (2019). "Low‐Gradient Severe Mitral Stenosis: Hemodynamic Profiles, Clinical Characteristics, and Outcomes". Journal of the American Heart Association. 8 (5). doi:10.1161/JAHA.118.010736. ISSN 2047-9980.
  6. 6.0 6.1 6.2 Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA; et al. (2014). "2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines". Circulation. doi:10.1161/CIR.0000000000000029. PMID 24589852.
  7. 7.0 7.1 Gerber MA, Baltimore RS, Eaton CB, Gewitz M, Rowley AH, Shulman ST; et al. (2009). "Prevention of rheumatic fever and diagnosis and treatment of acute Streptococcal pharyngitis: a scientific statement from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young, the Interdisciplinary Council on Functional Genomics and Translational Biology, and the Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Academy of Pediatrics". Circulation. 119 (11): 1541–51. doi:10.1161/CIRCULATIONAHA.109.191959. PMID 19246689.
  8. Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M; et al. (2007). "Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group". Circulation. 116 (15): 1736–54. doi:10.1161/CIRCULATIONAHA.106.183095. PMID 17446442.
  9. "2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary". Retrieved 4 March 2014.
  10. 10.0 10.1 Bonow RO, Carabello BA, Chatterjee K; et al. (2008). "2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". Circulation. 118 (15): e523–661. doi:10.1161/CIRCULATIONAHA.108.190748. PMID 18820172. Unknown parameter |month= ignored (help)
  11. Nishimura, Rick A.; Otto, Catherine M.; Bonow, Robert O.; Carabello, Blase A.; Erwin, John P.; Fleisher, Lee A.; Jneid, Hani; Mack, Michael J.; McLeod, Christopher J.; O’Gara, Patrick T.; Rigolin, Vera H.; Sundt, Thoralf M.; Thompson, Annemarie (2017). "2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines". Circulation. 135 (25). doi:10.1161/CIR.0000000000000503. ISSN 0009-7322.
  12. Nishimura, Rick A.; Otto, Catherine M.; Bonow, Robert O.; Carabello, Blase A.; Erwin, John P.; Fleisher, Lee A.; Jneid, Hani; Mack, Michael J.; McLeod, Christopher J.; O’Gara, Patrick T.; Rigolin, Vera H.; Sundt, Thoralf M.; Thompson, Annemarie (2017). "2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines". Circulation. 135 (25). doi:10.1161/CIR.0000000000000503. ISSN 0009-7322.
  13. Kang, Duk-Hyun; Kim, Jeong Hoon; Rim, Ji Hye; Kim, Mi-Jeong; Yun, Sung-Cheol; Song, Jong-Min; Song, Hyun; Choi, Kee-Joon; Song, Jae-Kwan; Lee, Jae-Won (2009). "Comparison of Early Surgery Versus Conventional Treatment in Asymptomatic Severe Mitral Regurgitation". Circulation. 119 (6): 797–804. doi:10.1161/CIRCULATIONAHA.108.802314. ISSN 0009-7322.
  14. Enriquez-Sarano, M; Tajik, A J; Schaff, H V; Orszulak, T A; Bailey, K R; Frye, R L (1994). "Echocardiographic prediction of survival after surgical correction of organic mitral regurgitation". Circulation. 90 (2): 830–837. doi:10.1161/01.CIR.90.2.830. ISSN 0009-7322.
  15. Enriquez-Sarano, M; Tajik, A J; Schaff, H V; Orszulak, T A; Bailey, K R; Frye, R L (1994). "Echocardiographic prediction of survival after surgical correction of organic mitral regurgitation". Circulation. 90 (2): 830–837. doi:10.1161/01.CIR.90.2.830. ISSN 0009-7322.
  16. Enriquez-Sarano, M; Tajik, A J; Schaff, H V; Orszulak, T A; Bailey, K R; Frye, R L (1994). "Echocardiographic prediction of survival after surgical correction of organic mitral regurgitation". Circulation. 90 (2): 830–837. doi:10.1161/01.CIR.90.2.830. ISSN 0009-7322.



Linked-in.jpg