The AHA Guidelines and Scientifi c Statements Handbook
The 1998 ACC/AHA Guidelines for the Manage-
ment of Patients with Valvular Heart Disease
compiled this information base and made recom-
mendations for diagnostic testing, treatment, and
physical activity [1]. These guidelines were exten-
sively revised in 2006 [2], and the major recommen-
dations of the 2006 guidelines are discussed in this
chapter.
The European Society of Cardiology guidelines
for the management of valvular heart disease (3)
were published in 2007 and are remarkably concor-
dant with the ACC/AHA recommendations. Where
applicable, the ESC recommendations are noted in
context with the ACC/AHA recommendations
which follow. The ESC recommendations are pri-
marily focused on indications for surgery and per-
cutaneous intervention, and these are highlighted
in Purple.
Echocardiography
Class I
1 Echocardiography is recommended for asymp-
tomatic patients with diastolic murmurs, continu-
ous murmurs, holosystolic murmurs, late systolic
murmurs, or murmurs associated with ejection
clicks or that radiate to the neck or back. (Level of
Evidence: C)
2 Echocardiography is recommended for patients
with heart murmurs and symptoms or signs of heart
failure, myocardial ischemia/infarction, syncope,
thromboembolism, infective endocarditis, or other
clinical evidence of structural heart disease. (Level of
Evidence: C)
3 Echocardiography is recommended for asymp-
tomatic patients who have grade 3 or louder mid-
peaking systolic murmurs. (Level of Evidence: C)
Class IIa
1 Echocardiography can be useful for the evalua-
tion of asymptomatic patients with murmurs associ-
ated with other abnormal cardiac physical fi ndings
or murmurs associated with an abnormal ECG or
chest X-ray. (Level of Evidence: C)
2 Echocardiography can be useful for patients
whose symptoms and/or signs are likely noncardiac
in origin but in whom a cardiac basis cannot be
excluded by standard evaluation. (Level of Evidence:
C)
Class III
1 Echocardiography is not recommended for
patients who have a grade 2 or softer midsystolic
murmur identifi ed as innocent or functional by an
experienced observer. (Level of Evidence: C)Quantifi cation of severity of valve
disease
Classifi cation of the severity of valve disease in adults
is listed in Table 18.1. The classifi cation for regurgi-
tant lesions is adapted from the recommendations
of the American Society of Echocardiography. Sub-
sequent sections of the current guidelines refer to
the criteria in Table 18.1 to defi ne severe valvular
stenosis or regurgitation. The ESC guidelines use the
same classifi cation system for severe aortic stenosis,
aortic regurgitation, and mitral regurgitation [3].Endocarditis prophylaxis
The following information is based on updated rec-
ommendations made by the AHA in 2007 [4] and
the 2008 focused update of the ACC/AHA Guide-
lines for the Management of Patients with Valvular
Heart Disease [5].Class IIa
Prophylaxis against infective endocarditis is proba-
bly recommended for the following high risk patients
for dental procedures that involve manipulation of
gingival tissue or the periapical region of teeth or
perforation of the oral mucosa:- Prosthetic cardiac valve or prosthetic material
used in cardiac valve repair (Level of Evidence: C) - Previous IE (Level of Evidence: C)
- Congenital heart disease (CHD) including:
- Unrepaired cyanotic CHD, including palliative
shunts and conduits. (Level of Evidence: C) - Completely repaired congenital heart defect
with prosthetic material or device, whether placed
by surgery or by catheter intervention, during the
fi rst 6 months after the procedure. (Level of Evi-
dence: C) - Repaired CHD with residual defects at the site
or adjacent to the site of a prosthetic patch or
prosthetic device (which inhibit endothelializa-
tion). (Level of Evidence: C)
- Unrepaired cyanotic CHD, including palliative
- Cardiac transplant recipients who develop cardiac
valvulopathy (Level of Evidence: C)