ACC-AHA 2020 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease
ACC/AHA｜循環器 / 弁膜疾患｜156 ページ｜チャンク 1577｜推奨 7 件｜current
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| 頁 | クラス | レベル | 推奨文 | 表 |
|---|---|---|---|---|
| p.12 | 1 A | Downloaded from http://ahajournals.org by on October 7, 2026 Recommendation-Specific Supportive Text 1. The risk of developing IE is highest in patients with a prosthetic valve, prior IE, or congenital heart disease with residual flow disturbances.3 IE has been reported to occur after transcatheter aortic valve implantation (TAVI) at rates equal to or exceeding those associated with surgical aortic valve replacement (SAVR) and is associated with a high 1-year mortality rate of 75%.23,24 IE may also occur after valve repair with prosthetic material, which results in high in-hospital and 1-year mortality rates, even with surgical intervention.25,26 IE appears to be more common in heart transplant recipients than in the general population, according to limited data.3 The risk of IE is highest in the first 6 months after transplantation because of endothelial disruption, high-intensity immunosuppressive therapy, frequent central venous catheter access, and frequent endomyocardial biopsies.3 Persons at risk of IE can reduce potential sources of bacterial seeding by maintaining optimal oral health through regular professional dental care and the use of appropriate dental products, such as manual, powered, and ultrasonic toothbrushes; dental floss; and other plaque-removal devices. 2. Transient bacteremia is commonly seen in routine activities such as brushing teeth and flossing (20% to 68%), using toothpicks (20% to 40%), and simply chewing food (7% to 51%). | ||
| p.19 | 1 A | Recommendation-Specific Supportive Text CLINICAL STATEMENTS 1. In patients who have had a valve intervention, most cardiologists continue to see patients for a clinical history and physical examination at annual intervals, or more frequently if needed for symptoms or concurrent conditions. A baseline TTE study is recommended after all valve interventions, including replacement with a prosthetic valve (see Section 11.1). This baseline postprocedural study ideally is performed 1 to 3 months after intervention to ensure loading conditions have returned to normal, but in some cases it may need to be done during the index hospitalization for the patient’s convenience. The timing of subsequent periodic imaging after valve intervention is based on the type of valve prosthesis or repair, length of time after valve intervention, residual valve dysfunction, ventricular size and systolic function, and any concurrent cardiac conditions (Table 12). TTE is the standard approach for periodic imaging, supplemented by TEE when prosthetic mitral valve dysfunction is a concern (see Section 11.1). Additional imaging with CT, fluoroscopy CMR, or PET is reserved for patients for whom there is concern about valve dysfunction (see Section 11.1) or endocarditis (see Section 12.1).1,2 AND GUIDELINES | ||
| p.22 | 1 A | 2. In symptomatic patients with severe AS (Stage D1, aortic velocity ≥4.0 m/s or mean pressure gradient ≥40 mm Hg), exercise testing should not be performed because of the risk of severe hemodynamic compromise.5 3: Harm B-NR Downloaded from http://ahajournals.org by on October 7, 2026 Synopsis In a subset of asymptomatic patients with severe AS, exercise testing can provide additional diagnostic and prognostic information, but it should not be performed in symptomatic patients with severe AS. Recommendation-Specific Supportive Text 1. When performed under the direct supervision of an experienced clinician, with close monitoring of blood pressure and ECG, exercise testing in asymptomatic patients is relatively safe and may provide information that is not evident during the initial clinical evaluation, particularly when the patient’s functional capacity is unclear. Patients with symptoms provoked by exercise testing should be considered symptomatic, even if the clinical history is equivocal. Although it can be challenging to separate normal exercise limitations from abnormal symptoms that are attributable to AS, particularly in elderly sedentary patients, exercise-induced angina, excessive dyspnea early in exercise, dizziness, and syncope are consistent with symptoms of AS. Exercise testing can also identify a limited exercise capacity or an abnormal blood pressure response. Recording aortic valve hemodynamics with exercise is of limited value and does not show additive value for predicting clinical outcome when baseline measures of hemodynamic severity and functional status are considered. In addition, recording hemodynamics with exercise is challenging, and simpler parameters are adequate in most patients.2–4,6–11 | ||
| p.23 | 1 A | with asymptomatic AS in the SEAS (Simvastatin Ezetimibe in Aortic Stenosis) study, hypertension (n=1340) was associated with a 56% higher rate of ischemic cardiovascular events and a 2-fold higher mortality rate (both P<0.01) than those seen in normotensive patients with AS, although no impact on progression of valve stenosis leading to symptoms requiring AVR was seen. Medical therapy for hypertension follows standard guidelines, starting at a low dose and gradually titrating upward as needed to achieve blood pressure control. There are no studies addressing specific antihypertensive medications in patients with AS, but diuretics may reduce stroke volume, particularly if the LV chamber is small at baseline. In theory, ACE inhibitors may be advantageous because of the potential beneficial effects on LV fibrosis, in addition to control of hypertension. Consideration should be given to a higher target blood pressure for patients with AS than is recommended for the general population, but this is an underexplored area, and further data are needed before a different target blood pressure can be recommended for patients with AS.1–3,9–13 CLINICAL STATEMENTS AND GUIDELINES | ||
| p.28 | 1 A | risk of bleeding complications related to VKA therapy and more often require interruption of VKA therapy for noncardiac surgical and interventional procedures. It is reasonable to use a bioprosthetic valve in patients >65 years of age to avoid the risks of anticoagulation because the durability of the valve exceeds the expected years of life. 6. Replacement of the aortic valve with a pulmonary autograft (the Ross procedure) is a complex operation involving replacement of the aortic valve by the patient’s own pulmonic valve, along with placement of a pulmonic valve homograft. The Ross procedure allows the patient to avoid a prosthetic heart valve and the risks of anticoagulation and it provides excellent valve hemodynamics. However, both the pulmonic homograft in the pulmonic position and the pulmonary autograft (the neoaortic valve) are at risk of valve degeneration. The failure of the Ross procedure is most often attributable to regurgitation of the neoaortic valve in the second decade after the operation. In addition, at least half of pulmonic homograft valves require reintervention within 10 to 20 years. Calcification of the homograft and adhesions between the homograft and neoaorta may increase the difficulty of reoperation. The Ross procedure typically is reserved for younger patients with appropriate anatomy and tissue characteristics for whom anticoagulation is either contraindicated or undesirable, and it is performed only at Comprehensive Valve Centers by surgeons experienced in this procedure.11–13,32 | ||
| p.28 | 1 A | Downloaded from http://ahajournals.org by on October 7, 2026 | ||
| p.57 | 1 A | Downloaded from http://ahajournals.org by on October 7, 2026 |