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]
Overview
Patients with mitral stenosis who develop atrial fibrillation require anticoagulation and rate control. Medical therapy for mitral stenosis includes anticoagulation and rate control (to increase diastolic filling time) in those 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), mitral valve replacement.
Medical Therapy
Asymptomatic Patients
In asymptomatic patients, use endocarditis prophylaxis and chronic anticoagulation for intermittent or chronic atrial fibrillation, systemic embolism and marked LA enlargement (>55mm).
Symptomatic Patients
Anticoagulation
- Anticoagulant or antiplatelet medications (blood thinners) may be used to prevent clots from forming in patients with atrial fibrillation. The 2006 ACC/AHA guidelines on the management of valvular heart disease recommended long-term oral anticoagulation in patients with mitral stenosis who have a prior embolic event, left atrial thrombus, or atrial fibrillation.[4][5]
Digoxin
- Digitalis may be used to strengthen the heartbeat and to slow 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.
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.
2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary[6]
| 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) " |
2008 and Incorporated 2006 ACC/AHA Guidelines for the Management of Patients with Valvular Heart Disease (DO NOT EDIT)[7]
Systemic Embolization Prevention (DO NOT EDIT)[7]
| 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) " |
| “ | * This recommendation is based on a grade C level of evidence given by the American College of Chest Physicians Fourth Consensus Conference on Antithrombotic Therapy. [8] | ” |
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.
- ↑ Salem DN, O'Gara PT, Madias C, Pauker SG, American College of Chest Physicians (2008). "Valvular and structural heart disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition)". Chest. 133 (6 Suppl): 593S–629S. doi:10.1378/chest.08-0724. PMID 18574274.
- ↑ Singer DE, Albers GW, Dalen JE, Fang MC, Go AS, Halperin JL; et al. (2008). "Antithrombotic therapy in atrial fibrillation: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition)". Chest. 133 (6 Suppl): 546S–592S. doi:10.1378/chest.08-0678. PMID 18574273.
- ↑ 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 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) - ↑ Levine HJ, Pauker SG, Eckman MH (1995). "Antithrombotic therapy in valvular heart disease". Chest. 108 (4 Suppl): 360S–370S. PMID 7555189. Unknown parameter
|month=ignored (help)