The AHA Guidelines and Scientifi c Statements Handbook
Rheumatic fever prophylaxis
Class I
Patients who have had rheumatic fever with or
without carditis (including patients with MS) should
receive prophylaxis for recurrent rheumatic fever.
(Level of Evidence: B)
Specifi c valve lesions
Aortic stenosis
Echocardiography (imaging, spectral, and color
Doppler) in AS
Class I
1 Echocardiography is recommended for the diag-
nosis and assessment of AS severity. (Level of Evi-
dence: B)
2 Echocardiography is recommended in patients
with AS for the assessment of LV wall thickness, size,
and function. (Level of Evidence: B)
3 Echocardiography is recommended for re-
evaluation of patients with known AS and
changing symptoms or signs. (Level of Evidence:
B)
4 Echocardiography is recommended for the assess-
ment of changes in hemodynamic severity and LV
function in patients with known AS during preg-
nancy. (Level of Evidence: B)
5 Transthoracic echocardiography is recommended
for re-evaluation of asymptomatic patients: every
year for severe AS; every 1 to 2 years for moderate
AS; and every 3 to 5 years for mild AS. (Level of
Evidence: B)Exercise testing
Class IIb
Exercise testing in asymptomatic patients with AS
may be considered to elicit exercise induced symp-
toms and abnormal blood pressure responses. (Level
of Evidence: B)
Class III
Exercise testing should not be performed in symp-
tomatic patients with AS. (Level of Evidence: B)Quantitative (cath or echo)
Regurgitant volume (ml/beat) Less than 30 30–59 Greater than or equal to 60
Regurgitant fraction (%) Less than 30 30–49 Greater than or equal to 50
Regurgitant orifi ce area (cm^2 ) Less than 0.20 0.2–0.39 Greater than or equal to 0.40
Additional essential
criteria
Left atrial size Enlarged
Left ventricular size Enlarged
Right-sided valve disease
Severe tricuspid stenosis Valve area less than 1.0 cm^2
Severe tricuspid regurgitation Vena contracta width greater than 0.7 cm and systolic fl ow reversal in hepatic veins
Severe pulmonic stenosis Jet velocity greater than 4 m per second or maximum gradient greater than 60 mm Hg
Severe pulmonic regurgitation Color jet fi lls outfl ow tract
Dense continuous wave Doppler signal with a steep deceleration slope
- Valve gradients are fl ow dependent and when used as estimates of severity of valve stenosis should be assessed with knowledge of cardiac output or forward fl ow
across the valve.
** Quantitation of valvular regurgitation adopted from Zoghbi WA, Enriquez-Sarano M, Foster E, et al. Recommendations for evaluation of the severity of native valvular
regurgitation with two-dimensional and Doppler echocardiography. J Am Soc Echocardiogr 2003;16:777–802.
The ESC guidelines provide identical defi nitions of severe aortic stenosis, aortic regurgitation, and mitral regurgitation [3].
Table 18.1. Continued
Mitral regurgitation**
Mild Moderate Severe