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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 e115 CLINICAL STATEMENTS AND GUIDELINES 6.2.1.5 Diagnostic Testing: Exercise Testing Recommendation for Diagnostic Testing: Exercise Testing in Patients With Rheumatic MS COR LOE Recommendation 1 C-LD 1. In patients with rheumatic MS and a discrepancy between resting echocardiographic findings and clinical symptoms, exercise testing with Doppler or invasive hemodynamic assessment is recommended to evaluate symptomatic response, exercise capacity, and the response of the mean mitral gradient and pulmonary artery pressure.1–5 Synopsis Exercise testing with either Doppler echocardiography or cardiac catheterization is important when the resting hemodynamics do not match the clinical symptoms in patients with rheumatic MS. Recommendation-Specific Supportive Text 1. Exercise testing with hemodynamics is helpful in the management of rheumatic MS when a patient’s symptoms seem significantly greater than or less than would be expected from TTE. Results have been published in which both exercise and dobutamine were used with Doppler echocardiography, although exercise is preferred in general as the more physiological test.1–6 Most experience is with treadmill exercise, with images and Doppler obtained immediately after stress, but bicycle exercise allows data acquisition at various stages of exercise. Bicycle exercise testing during cardiac catheterization can also be performed for direct measurements of pulmonary artery wedge pressure and pulmonary pressures at rest and with exercise. Simple functional capacity helps to quantify the patient’s symptoms. Changes in valve gradient should be measured, as well as the estimated pulmonary artery systolic pressure. If the patient cannot exercise, increasing the heart rate with maneuvers such as leg lifts or sit-ups may be useful. 6.2.2 Medical Therapy Recommendations for Medical Therapy in Patients With Rheumatic MS Referenced studies that support the recommendations are summarized in Online Data Supplement 20. COR LOE Recommendations 1 C-LD 1. In patients with rheumatic MS and 1) AF, 2) a prior embolic event, or 3) an LA thrombus, anticoagulation with a VKA is indicated.1–7 2a C-LD 2. In patients with rheumatic MS and AF with a rapid ventricular response, heart rate control can be beneficial.8 2a A 3. In patients with rheumatic MS in normal sinus rhythm with symptomatic resting or exertional sinus tachycardia, heart rate control can be beneficial to manage symptoms.9–15 Synopsis In patients with rheumatic MS and AF, anticoagulation decreases the incidence of thromboembolic events. Anticoagulation can also decrease the incidence of thromboembolic events in patients with rheumatic MS if there has been a prior embolic event or if an LA thrombus was visualized. In symptomatic patients with MS who are in normal sinus rhythm and have tachycardia, heart rate control with beta blockers, calcium channel blockers, or ivabradine will lengthen the diastolic filling period and lower LA pressure. However, routine use of heart rate control for patients with rheumatic MS in normal sinus rhythm in the absence of tachycardia may result in chronotropic incompetence, preventing an adequate cardiac output response to exercise. Recommendation-Specific Supportive Text 1. Patients with rheumatic MS with AF and prior embolic events are at high risk of arterial embolization when AF or an LA thrombus is present. Treatment with VKA anticoagulation will decrease the incidence of these events.3–7,16 It is controversial whether long-term anticoagulation should be given to patients with rheumatic MS in normal sinus rhythm on the basis of LA enlargement or spontaneous contrast on TEE.17,18 Patients with very large left atria have more spontaneous echocardiographic contrast and lower LA appendage Doppler velocities,19 which have been associated with a higher rate of embolic events, but no data directly link large left atria to embolic events. Non–vitamin K oral anticoagulation has not been studied in patients with rheumatic MS, and these patients were excluded from the randomized AF trials. In addition to the much higher risk of embolization with rheumatic valve disease as compared with other causes of valve disease, there is concern that rheumatic disease also affects the atrial muscle, resulting in an increased risk of blood flow stasis and thrombosis in the body of the LA, as well as the LA appendage.1 Further studies are required to confirm these findings.2 2. Patients with rheumatic MS are prone to developing atrial arrhythmias—specifically AF. Significant detrimental hemodynamic consequences may be associated with the acute development of AF, primarily from the rapid ventricular response, which shortens the diastolic filling period and increases LA pressure.16 The treatment of acute AF consists of anticoagulation and control of the heart rate response with negative dromotropic agents. If the rate cannot be adequately controlled with medications, cardioversion may be necessary to improve hemodynamics. In the stable patient, the decision Downloaded from http://ahajournals.org by on October 7, 2026