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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 e83 CLINICAL STATEMENTS AND GUIDELINES

Synopsis

With the absence of RCTs addressing the efficacy of antibiotic prophylaxis for prevention of IE1,12–14 and given uncertainty about which patient populations are at highest risk, these recommendations are based on pathophysiological considerations, limited data, and clinical expertise. A prospective study demonstrated that prophylactic antibiotics given to patients for what is typically considered a high-risk dental procedure reduced but did not eliminate the incidence of bacteremia.2 A 2013 Cochrane Database systematic review of antibiotic prophylaxis for the prevention of IE in dentistry concluded that there is no evidence to determine whether antibiotic prophylaxis is effective or ineffective, highlighting the need for further study of this long-standing clinical dilemma.1 Epidemiological data conflict with regard to changes in the incidence of IE after adoption of more limited antibiotic prophylaxis guidelines.15–22 The consensus of the writing committee is that antibiotic prophylaxis is reasonable for the subset of patients at highest risk of developing IE and at high risk of experiencing adverse outcomes from IE. There is no evidence for IE prophylaxis in gastrointestinal procedures or genitourinary procedures, in the absence of known active infection.

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%). The incidence of IE after most procedures is low, with no controlled data supporting the benefit of antibiotic prophylaxis. Indiscriminate use of antibiotics can be associated with the development of resistant organisms, Clostridium difficile colitis, unnecessary expense, and drug toxicity. The rate of transient bacteremia during or immediately after endoscopy is 2% to 5%, and the organisms typically identified are unlikely to cause IE.11,27,28 The rate of bacteremia does not increase with biopsy, polypectomy, or sphincterotomy. Some gastrointestinal procedures are associated with rates of bacteremia higher than that for simple endoscopy; these procedures include esophageal dilation (as high as 45%), sclerotherapy (31%), and endoscopic retrograde cholangiopancreatography (6% to 18%).29 However, no studies have shown reduced rates of IE with antibiotic prophylaxis. Surgery, instrumentation, or diagnostic procedures that involve the genitourinary tract may cause bacteremia. In the absence of infection, the rate of bacteremia after urinary tract procedures is low. In patients with bacteriuria, antimicrobial therapy before elective procedures, including lithotripsy, typically is provided.30

2.4.3 Anticoagulation for AF in Patients With VHD

Recommendations for Anticoagulation for AF in Patients With VHD Referenced studies that support the recommendations are summarized in Online Data Supplement 2. COR LOE Recommendations

1 A 1.  For patients with AF and native valve heart disease (except rheumatic mitral stenosis [MS]) or who received a bioprosthetic valve >3 months ago, a non–vitamin K oral anticoagulant (NOAC) is an effective alternative to VKA anticoagulation and should be administered on the basis of the patient’s CHA2DS2-VASc score.1,2

1 C-EO 2.  For patients with AF and rheumatic MS, long-term VKA oral anticoagulation is recommended.

2a B-NR 3.  For patients with new-onset AF ≤3 months after surgical or transcatheter bioprosthetic valve replacement, anticoagulation with a VKA is reasonable.3–6

3: Harm B-R 4.  In patients with mechanical heart valves with or without AF who require long-term anticoagulation with VKA to prevent valve thrombosis, NOACs are not recommended.7

Synopsis

Patients with VHD and AF should be evaluated for risk of thromboembolic events and to treat them with oral anticoagulation if they are at high risk. VKAs are the anticoagulation drugs of choice for patients with rheumatic MS and mechanical heart valves. NOACs are an alternative to VKAs in patients with AF and 1) with

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