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Otto et al 2020 ACC/AHA Guideline for the Management of Valvular Heart Disease February 2, 2021 Circulation. 2021;143:e72–e227. DOI: 10.1161/CIR.0000000000000923 e82 CLINICAL STATEMENTS AND GUIDELINES isolated muscle training may be used to strengthen individual muscle groups. Most patients with LV systolic dysfunction and severe VHD will undergo intervention for the valve itself. However, if intervention is declined or not feasible, standard GDMT drug therapy for LV systolic dysfunction should be continued, including diuretics, angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), beta blockers, aldosterone antagonists, and/or sacubitril/valsartan and biventricular pacing, as indicated in the guidelines for heart failure (HF).1 In patients with stenotic valve lesions, abrupt lowering of blood pressure should be avoided.1 Rheumatic fever prophylaxis and infective endocarditis (IE) prophylaxis should be provided to appropriate groups of patients, as outlined in Sections 2.4.1 and 2.4.2. The maintenance of optimal oral health remains the most important component of an overall healthcare program in preventing IE. Influenza and pneumococcal vaccinations should follow standard recommendations in patients with VHD. For subsets of patients with AF and VHD, anticoagulation is discussed in Section 2.4.3. 2.4.1 Secondary Prevention of Rheumatic Fever Recommendation for Secondary Prevention of Rheumatic Fever COR LOE Recommendation 1 C-EO 1. In patients with rheumatic heart disease, secondary prevention of rheumatic fever is indicated (Tables 6 and 7).1 Synopsis Rheumatic fever is an important cause of VHD worldwide, although it is less common in high-income countries. Rapid detection and treatment of streptococcal pharyngitis constitute primary prevention of rheumatic fever. For patients with previous episodes of rheumatic fever or in those with evidence of rheumatic heart disease, long-term antistreptococcal prophylaxis is indicated for secondary prevention.1 Recommendation-Specific Supportive Text 1. Recurrent rheumatic fever is associated with a worsening of rheumatic heart disease. However, infection with group A streptococcus does not have to be symptomatic to trigger a recurrence, and rheumatic fever can recur even when the symptomatic infection is treated. Prevention of recurrent rheumatic fever requires long-term antimicrobial prophylaxis rather than recognition and treatment of acute episodes of group A streptococcus pharyngitis. The recommended treatment regimens and duration of secondary prophylaxis are shown in Tables 6 and 7. 2.4.2 IE Prophylaxis Recommendations for IE Prophylaxis Referenced studies that support the recommendations are summarized in Online Data Supplement 1. COR LOE Recommendations 2a C-LD 1. Antibiotic prophylaxis is reasonable before dental procedures that involve manipulation of gingival tissue, manipulation of the periapical region of teeth, or perforation of the oral mucosa in patients with VHD who have any of the following1–9: a. Prosthetic cardiac valves, including transcatheter-implanted prostheses and homografts. b. Prosthetic material used for cardiac valve repair, such as annuloplasty rings, chords, or clips. c. Previous IE. d. Unrepaired cyanotic congenital heart disease or repaired congenital heart disease, with residual shunts or valvular regurgitation at the site of or adjacent to the site of a prosthetic patch or prosthetic device. e. Cardiac transplant with valve regurgitation attributable to a structurally abnormal valve. 3: No Benefit B-NR 2. In patients with VHD who are at high risk of IE, antibiotic prophylaxis is not recommended for nondental procedures (eg, TEE, esophagogastroduodenoscopy, colonoscopy, or cystoscopy) in the absence of active infection.10,11 Table 6. Secondary Prevention of Rheumatic Fever Antibiotics for Prevention Dosage* Penicillin G benzathine 1.2 million U intramuscularly every 4 wk† Penicillin V potassium 250 mg orally twice daily Sulfadiazine 1 g orally once daily Macrolide or azalide antibiotic (for patients allergic to penicillin and sulfadiazine)‡ Varies *In patients with documented valvular heart disease, the duration of rheumatic fever prophylaxis should be ≥10 y or until the patient is 40 y of age (whichever is longer). Lifelong prophylaxis may be recommended if the patient is at high risk of group A streptococcus exposure. Secondary rheumatic heart disease prophylaxis is required even after valve replacement. †Administration every 3 wk is recommended in certain high-risk situations. ‡Macrolide antibiotics should not be used in persons taking other medications that inhibit cytochrome P450 3A, such as azole antifungal agents, HIV protease inhibitors, and some selective serotonin reuptake inhibitors. Adapted from Gerber et al.1 Table 7. Duration of Secondary Prophylaxis for Rheumatic Fever Type Duration After Last Attack* Rheumatic fever with carditis and residual heart disease (persistent VHD†) 10 y or until patient is 40 y of age (whichever is longer) Rheumatic fever with carditis but no residual heart disease (no valvular disease†) 10 y or until patient is 21 y of age (whichever is longer) Rheumatic fever without carditis 5 y or until patient is 21 y of age (whichever is longer) *Lifelong prophylaxis may be recommended if the patient is at high risk of group A streptococcus exposure. Secondary rheumatic heart disease prophylaxis is required even after valve replacement. †Clinical or echocardiographic evidence. VHD indicates valvular heart disease. Adapted from Gerber et al.1 Downloaded from http://ahajournals.org by on October 7, 2026