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.[1][2][3] 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
The goal of medical treatment for mitral stenosis is to reduce recurrence of rheumatic fever, provide prophylaxis for infective endocarditis, reduce symptoms of pulmonary congestion (eg, orthopnea, paroxysmal nocturnal dyspnea), control the ventricular rate if atrial fibrillation is present, and prevent thromboembolic complications. [12]
Because rheumatic fever is the primary cause of mitral stenosis, secondary prophylaxis against group A beta-hemolytic streptococci (GAS) is recommended. [13] Duration of prophylaxis depends on the number of previous attacks, the time elapsed since the last attack, the risk of exposure to GAS infections, the age of the patient, and the presence or absence of cardiac involvement. Penicillin is the agent of choice for secondary prophylaxis, but sulfadiazine or a macrolide or azalide are acceptable alternatives in individuals allergic to penicillin (Tables 1 and 2).
A European study involving 315 patients with rheumatic mitral stenosis showed a significantly slower progression of rheumatic mitral stenosis in patients treated with statins compared with patients not taking statins. These findings could have an important impact in the early medical therapy of patients with rheumatic heart disease. [14]
Initial symptoms of pulmonary congestion can be safely treated by diuretics. Dietary sodium restriction and nitrates decrease preload and can be of additional benefit. Careful use of beta-blockers in patients with a normal sinus rhythm can prolong the diastolic filling time and thus decrease in left atrial pressure. In general, afterload reduction should be avoided as it can cause hypotension.
In a randomized crossover study, Saggu et al investigated the comparative efficacy of ivabradine and metoprolol on symptoms, hemodynamics, and exercise parameters in 33 patients with mild-to-moderate mitral stenosis (mitral valve area, 1-2 cm) in normal sinus rhythm. They found evidence that metoprolol and ivabradine reduced patients’ symptoms and improved hemodynamics significantly from baseline with a similar efficacy. The investigators concluded that ivabradine can be used safely and effectively in patients with mitral stenosis in normal sinus rhythm who are intolerant to or contraindicated for beta-blocker therapy. [15]
Atrial fibrillation is common in mitral stenosis and often leads to a rapid ventricular rate with reduced diastolic filling time and increased left atrial pressure. Although patients with mitral stenosis have a reduced average early diastolic strain in the presence of atrial fibrillation compared to normal sinus rhythm, those with mitral stenosis and atrial fibrillation show a loss of atrial late diastolic contraction as well as a reduction in early diastolic shortening of the left atrial myocardium. [16]
The ventricular rate of atrial fibrillation can be slowed acutely by the administration of intravenous beta-blocker or calcium channel blocker therapy (diltiazem or verapamil). The rate and/or rhythm can be controlled long-term with oral beta-blockers, calcium channel blockers, amiodarone, or digoxin.
In the patient with mild mitral stenosis and recent-onset (< 6 mo) atrial fibrillation, conversion to sinus rhythm can be accomplished with pharmacologic agents or electrical cardioversion. In this circumstance, anticoagulation therapy should be given for at least 3 weeks prior to cardioversion. Alternatively, a TEE can be performed to exclude the presence of left atrial thrombus, prior to cardioversion. Patients who are successfully converted to sinus rhythm should receive long-term anticoagulation and antiarrhythmic drugs. Warfarin should be used for anticoagulation. The novel anticoagulants dabigatran and rivaroxaban was approved for nonvalvular atrial fibrillation; these drugs have not been evaluated in patients with heart valve disease. [17]
Surgical correction of the mitral stenosis is indicated if embolization is recurrent, despite adequate anticoagulation therapy.
In a retrospective study (2001-2015) of 318 patients with late onset of atrial fibrillation following mitral valve repair for type II dysfunction, significant risk factors for late atrial fibrillation were small ring annuloplasty, left atrial diameter, and pressure half-time. [18] In addition, affected patients developed recurrent myocardial infarction more often than those without late-onset atrial fibrillation.
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.[4]
Diuretics
Diuretics may be used to remove excess fluid in the lungs in patients with pulmonary edema.
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):[5]
- 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:[5]
- 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.[6]
| 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.[6]
| 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.[7][8]
2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary (DO NOT EDIT)[5]
Medical Therapy (DO NOT EDIT)
| Class I |
"1. Anticoagulation (vitamin K antagonist or heparin) is indicated in patients with:
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| 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) " |
2008 and Incorporated 2006 ACC/AHA Guidelines for the Management of Patients with Valvular Heart Disease (DO NOT EDIT)[9]
Systemic Embolization Prevention (DO NOT EDIT)[9]
| 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) " |
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.
- ↑ 5.0 5.1 5.2 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.
- ↑ 6.0 6.1 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.
- ↑ 9.0 9.1 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
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