Focused Update: Infective Endocarditis Prophylaxis in Patients with Valvular Heart DiseaseFocused Update: Infective Endocarditis Prophylaxis in Patients with Valvular Heart Disease Recent changes in AHA recommendations for infective endocarditis prophylaxis have necessitated several important revisions to the 2006 guidelines. Sponsoring Organizations: American College of Cardiology, American Heart Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons Background and Purpose: Since the publication of the 2006 ACC/AHA Guidelines for the Management of Valvular Heart Disease, new evidence about prophylaxis for infective endocarditis (IE) has emerged, and a new revision of the AHA guidelines on prevention of IE has been published (JW Cardiol May 30 2007). This 2008 focused update of the 2006 valvular heart disease guidelines pertains only to recommendations related to IE prophylaxis. Key Points: 1. Although IE is a serious condition, the efficacy of antimicrobial prophylaxis is uncertain in all but a few select instances. Therefore, there are no longer any Class I recommendations for IE prophylaxis in patients with valvular heart disease. 2. Antibiotic prophylaxis during dental procedures would prevent only a small proportion of cases of IE, even if it were 100% effective. 3. IE prophylaxis during dental procedures is appropriate only in patients with underlying cardiac conditions associated with the highest risk for adverse outcomes. These conditions include: prosthetic valves or material prior IE unrepaired cyanotic congenital heart disease (CHD), including shunts and conduits complete CHD repair within the previous 6 months repaired CHD with residual defects valve regurgitation secondary to structural abnormalities in cardiac transplant recipients 4. In such high-risk patients, prophylaxis is appropriate for all dental procedures involving manipulation of gingival tissue or the periapical region of teeth, or perforation of oral mucosa (Class IIa). 5. Increased lifetime risk for IE alone is not an indication for antibiotic prophylaxis. 6. Antibiotic IE prophylaxis is no longer indicated in patients with aortic stenosis, mitral stenosis, or symptomatic or asymptomatic mitral valve prolapse. 7. Antibiotic IE prophylaxis is no longer indicated in adolescents and young adults with native heart valve disease. 8. Genitourinary and gastrointestinal tract procedures (transesophageal echocardiography, esophagogastroduodenoscopy, colonoscopy, etc.) do not warrant IE prophylaxis unless active infection is present. Comment: These guidelines are a considerable departure from prior recommendations and emphasize the need for an evidence-based approach to IE prophylaxis. Although these guidelines provide more clarity for providers and patients, clinicians changing their practice will no doubt encounter established expectations in patients with most forms of valvular heart disease. In instances for which data are lacking, such as bicuspid aortic valves, coarctation of the aorta, severe MVP, or hypotrophic obstructive cardiomyopathy, patient preferences should be assessed; if risks associated with antibiotics are low, providers and patients may feel more comfortable continuing to use prophylaxis. -- JoAnne M. Foody, MD Published in Journal Watch Cardiology August 20, 2008 Citation(s): Nishimura RA et al. for the 2006 Valvular Heart Disease Writing Committee. ACC/AHA 2008 guideline update on valvular heart disease: Focused update on infective endocarditis. J Am Coll Cardiol 2008 Aug 19; 52:676 Posted by : chpantip , E-mail : (chpantip@medicine.psu.ac.th) , Date : 2008-08-26 , Time : 10:58:19 , From IP : 172.29.3.158 |
