p.10 抽出テキスト

Otto et al 2020 ACC/AHA Guideline for the Management of Valvular Heart Disease

Circulation. 2021;143:e72–e227. DOI: 10.1161/CIR.0000000000000923 February 2, 2021 e81 CLINICAL STATEMENTS AND GUIDELINES

patients with VHD, there is still a subset of patients in whom hemodynamic catheterization is necessary to ensure that the proper decision about treatment is made. If noninvasive testing yields inconclusive data, particularly in the symptomatic patient, or if there is a discrepancy between the noninvasive tests and clinical findings, a hemodynamic cardiac catheterization with direct intracardiac measurements of transvalvular pressure gradients and cardiac output measurements provides valuable clinical information. Severity of stenosis may be underestimated when imaging is difficult or when the Doppler beam is not aligned parallel to the direction of the high-velocity jet. Severity of valve regurgitation may be overestimated or underestimated if the image or Doppler data quality is suboptimal. Contrast angiography is sometimes useful for a semiquantitative assessment of the severity of regurgitation in those instances in which the noninvasive results are discordant with the physical examination.1 A major advantage of cardiac catheterization is the measurement of intracardiac pressures and pulmonary vascular resistance, which may further aid in decision-making about valve intervention. Diagnostic interventions that can be performed in the catheterization laboratory include the use of dobutamine in low-flow states, pulmonary vasodilators in pulmonary hypertension, and exercise hemodynamics in patients with discrepant symptoms.1,2 A hemodynamic catheterization needs to be done with meticulous attention to detail by persons with knowledge and expertise in assessing patients with VHD.

2.3.5 Diagnostic Testing: Exercise Testing

In a subset of patients, exercise stress testing will be of additional value in determining optimal therapy. Because of the slow, insidious rate of progression of many valve lesions, patients may deny symptoms as they gradually limit their activity level over several years to match the gradual limitations imposed by the valve lesion. In patients with an equivocal history of symptoms, exercise testing helps identify those who are truly symptomatic.1,2 Exercise stress testing (ie, examining the exercise capacity and blood pressure response) is of prognostic value in patients with asymptomatic valve disease and provides further information about the timing of a potential intervention.3–11 It is important that exercise testing in patients with severe VHD always be performed by trained operators, with continuous monitoring of the ECG and blood pressure.

2.4 Basic Principles of Medical Therapy

In patients being evaluated for VHD, standard GDMT for cardiac risk factors, including hypertension, diabetes mellitus, and hyperlipidemia, should not be neglected. Heart-healthy lifestyle factors (exercising, consuming a healthy diet, not smoking, and maintaining a normal body size) are no different for patients with VHD than for the general population. Many patients with asymptomatic VHD feel better with regular aerobic exercise to improve cardiovascular fitness.1–3 Although heavy isometric repetitive training might increase LV afterload, resistive training with small free weights or repetitive

Table 4.  Stages of VHD

Stage Definition Description A At risk Patients with risk factors for development of VHD B Progressive Patients with progressive VHD (mild to moderate severity and asymptomatic) C Asymptomatic severe Asymptomatic patients who have the criteria for severe VHD:

C1: Asymptomatic patients with

severe VHD in whom the LV or RV remains compensated C2: Asymptomatic patients with

severe VHD with decompensation of the LV or RV

D Symptomatic severe Patients who have developed symptoms as a result of VHD LV indicates left ventricle; RV, right ventricle; and VHD, valvular heart disease.

Table 5.  Frequency of Echocardiograms in Asymptomatic Patients With VHD and Normal LV Function

Stage Type of Valve Lesion

Aortic Stenosis* Aortic Regurgitation Mitral Stenosis Mitral Regurgitation

Progressive (Stage B) Every 3–5 y (mild severity; Vmax 2.0–2.9 m/s) Every 3–5 y (mild severity) Every 3–5 y (MV area >1.5 cm2) Every 3–5 y (mild severity)

Every 1–2 y moderate severity; Vmax 3.0–3.9 m/s) Every 1–2 y (moderate severity) Every 1–2 y (moderate severity)

Severe asymptomatic (Stage C1) Every 6–12 mo (Vmax ≥4 m/s) Every 6–12 mo Every 1–2 y (MV area 1.0– 1.5 cm2) Every 6–12 mo

Dilating LV: More frequently Every year (MV area <1.0 cm2) Dilating LV: More frequently

Patients with mixed valve disease may require serial evaluations at intervals earlier than recommended for single-valve lesions. These intervals apply to most patients with each valve lesion and do not take into consideration the etiology of the valve disease.

*With normal stroke volume. LV indicates left ventricle; MV, mitral valve; VHD, valvular heart disease; and Vmax, maximum velocity.

Downloaded from http://ahajournals.org by on October 7, 2026