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February 2, 2021 Circulation. 2021;143:e72–e227. DOI: 10.1161/CIR.0000000000000923 e128 CLINICAL STATEMENTS AND GUIDELINES Otto et al 2020 ACC/AHA Guideline for the Management of Valvular Heart Disease 7.3.3 Medical Therapy Recommendations for Medical Therapy for Secondary MR Referenced studies that support the recommendations are summarized in Online Data Supplement 31. COR LOE Recommendations 1 A 1. Patients with chronic severe secondary MR (Stages C and D) and HF with reduced LVEF should receive standard GDMT for HF, including ACE inhibitors, ARBs, beta blockers, aldosterone antagonists, and/or sacubitril/valsartan, and biventricular pacing as indicated.1–11 1 C-EO 2. In patients with chronic severe secondary MR and HF with reduced LVEF, a cardiologist expert in the management of patients with HF and LV systolic dysfunction should be the primary MDT member responsible for implementing and monitoring optimal GDMT.9,12 Synopsis GDMT for HF with reduced LVEF in patients with severe secondary MR should be provided, in conjunction with a cardiology expert, in the management of HF. Recommendation-Specific Supportive Text 1. Chronic secondary MR usually develops as a result of LV systolic dysfunction. Thus, standard GDMT for HF forms the mainstay of therapy. Diuretics, beta blockers, ACE inhibitors or ARBs, and aldosterone antagonists help improve symptoms and/ or prolong life in patients with HF in general and probably do so even when HF is complicated by chronic secondary MR. GDMT can reduce LV volumes (reverse remodeling) in many patients, which reduces severity of secondary MR.1–11 2. Secondary MR is often responsive to GDMT (including coronary revascularization or cardiac resynchronization therapy in appropriate patients). Optimization of GDMT should be under the supervision of a cardiologist expert in the treatment of patients with HF to achieve optimal results and to determine with the MDT when symptoms are truly refractory to GDMT before decisions are made for surgical or transcatheter treatment.9,12 Table 18. Stages of Secondary MR Stage Definition Valve Anatomy Valve Hemodynamics* Associated Cardiac Findings Symptoms A At risk of MR Normal valve leaflets, chords, and annulus in a patient with CAD or cardiomyopathy No MR jet or small central jet area <20% LA on Doppler Small vena contracta <0.30 cm Normal or mildly dilated LV size with fixed (infarction) or inducible (ischemia) regional wall motion abnormalities Primary myocardial disease with LV dilation and systolic dysfunction Symptoms attributable to coronary ischemia or HF may be present that respond to revascularization and appropriate medical therapy B Progressive MR Regional wall motion abnormalities with mild tethering of mitral leaflet Annular dilation with mild loss of central coaptation of the mitral leaflets ERO <0.40 cm2† Regurgitant volume <60 mL Regurgitant fraction <50% Regional wall motion abnormalities with reduced LV systolic function LV dilation and systolic dysfunction attributable to primary myocardial disease Symptoms attributable to coronary ischemia or HF may be present that respond to revascularization and appropriate medical therapy C Asymptomatic severe MR Regional wall motion abnormalities and/or LV dilation with severe tethering of mitral leaflet Annular dilation with severe loss of central coaptation of the mitral leaflets ERO ≥0.40 cm2† Regurgitant volume ≥60 mL‡ Regurgitant fraction ≥50% Regional wall motion abnormalities with reduced LV systolic function LV dilation and systolic dysfunction attributable to primary myocardial disease Symptoms attributable to coronary ischemia or HF may be present that respond to revascularization and appropriate medical therapy D Symptomatic severe MR Regional wall motion abnormalities and/or LV dilation with severe tethering of mitral leaflet Annular dilation with severe loss of central coaptation of the mitral leaflets ERO ≥0.40 cm2† Regurgitant volume ≥60 mL‡ Regurgitant fraction ≥50% Regional wall motion abnormalities with reduced LV systolic function LV dilation and systolic dysfunction attributable to primary myocardial disease HF symptoms attributable to MR persist even after revascularization and optimization of medical therapy Decreased exercise tolerance Exertional dyspnea *Several valve hemodynamic criteria are provided for assessment of MR severity, but not all criteria for each category will be present in each patient. Categorization of MR severity as mild, moderate, or severe depends on data quality and integration of these parameters in conjunction with other clinical evidence. †The measurement of the proximal isovelocity surface area by 2D TTE in patients with secondary MR underestimates the true ERO because of the crescentic shape of the proximal convergence. ‡May be lower in low-flow states. 2D indicates 2-dimensional; CAD, coronary artery disease; ERO, effective regurgitant orifice; HF, heart failure; LA, left atrium; LV, left ventricular; MR, mitral regurgitation; and TTE, transthoracic echocardiogram. Downloaded from http://ahajournals.org by on October 7, 2026