Mitral stenosis medical therapy
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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]
- Paroxysmal, persistent, or permanent atrial fibrillation
- Prior embolization event
- Left atrial thrombus
Rate Control
Rate control with either beta blockers or calcium channel blocker is indicated in MS in the following conditions:[6]
- Atrial fibrillation associated with fast ventricular response (Class IIa, Level of Evidence C)
- Normal sinus rhythm plus symptoms associated with exercise (Class IIb, Level of Evidence B)
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]
2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines[10]
Recommendations for Medical Therapy in Patients With Rheumatic MS Referenced studies that support the recommendations are summarized in Online Data Supplement
| Class I |
| 1. In patients with rheumatic MS and 1) AF, 2) a prior embolic event, or 3) an LA thrombus, anticoagulation with a VKA is indicated(Level of Evidence: C-LD) |
| Class IIa |
| 2. In patients with rheumatic MS and AF with a rapid ventricular response, heart rate control can be beneficial(Level of Evidence: C-LD)
3. In patients with rheumatic MS in normal sinus rhythm with symptomatic resting or exertional sinus tachycardia, heart rate control can be beneficial to manage symptoms(Level of Evidence: A) |
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)[11]
Systemic Embolization Prevention (DO NOT EDIT)[11][12]
| 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[13]
| 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".[14][15] | 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".[16] |
| "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".[17] | |||
References
- ↑ 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.
- ↑ Dahl JC, Winchell P, Borden CW (1967). "Mitral stenosis. A long term postoperative follow-up". Arch Intern Med. 119 (1): 92–7. PMID 6015840.
- ↑ Roy SB, Gopinath N (1968). "Mitral stenosis". Circulation. 38 (1 Suppl): 68–76. PMID 4889600.
- ↑ Boon NA, Bloomfield P (2002). "The medical management of valvar heart disease". Heart. 87 (4): 395–400. PMC 1767079. PMID 11907022.
- ↑ 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.
- ↑ 6.0 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.
- ↑ 7.0 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.
- ↑ 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.
- ↑ "2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary". Retrieved 4 March 2014.
- ↑ Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F; et al. (2021). "2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Circulation. 143 (5): e72–e227. doi:10.1161/CIR.0000000000000923. PMID 33332150 Check
|pmid=value (help). - ↑ 11.0 11.1 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) - ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.