Medical Treatment of MS

Antibiotic prophylaxis
Recurrent rheumatic fever
Infective endocarditis
Restrict activities (moderate/severe mitral stenosis)
Severe exercise
Competitive sports
Arrhythmias
Prevent or control
Atrial fibrillation/flutter
Control ventricular rate
Anticoagulation: start with IV heparin and warfarin; when INR is 2 to 3 discontinue heparin
Restore sinus rhythm
Cardiac medications
Warfarin anticoagulation: INR at 2 to 3
Atrial fibrillation/supraventricular arrhythmias
Systemic emboli
LA thrombus
Pulmonary emboli
LV Systolic dysfunction
Elevated pulmonary venous pressure: diureticsa
"Heart failure"
Pulmonary congestion: diureticsa
Pulmonary edema: diuretics,a venodilators if necessarya
LV systolic dysfunction: digitalis, ACE inhibitors
Elevated systemic venous pressure and fluid retention: digitalis, diuretics, ACE inhibitors; blockers (second generation)
after patients are stabilized and there is LV systolic dysfunction.

Hurst's The Heart Chapter 77. Mitral Valve

Secondary Prevention of Rheumatoid Fever

(Prevention of Recurrent Attack)

recommendations by the American Heart

Association.

Patients for Which Antibiotic Prophylaxis Is

Recommended
(Prevention of IE)
Patient-Specific Risk
High risk
All prosthetic heart valves (including bioprosthetic and
homograft valves)
History of prior bacterial endocarditis
Complex cyanotic congenital heart disease
Surgical pulmonary shunts
Moderate risk
Mitral valve prolapse with significant regurgitation, or
leaflet thickening
Hypertrophic cardiomyopathy
Acquired valvular heart disease including stenosis,
regurgitation and rheumatic
Other congenital malformations (ostium primum ASD, VSD,
PDA, bicuspid aortic valve, coarctation)
Low risk
Mitral valve prolapse without evidence of regurgitation or
myxomatous leaflets
Physiologic murmurs
recommendations by the American Heart
Association.
Isolated secundum ASD

Endocarditis Prophylaxis Regimens for Dental, Oral,

Respiratory Tract, and Esophageal Procedures

Standard general prophylaxis

Amoxicillin
Adults: 2.0 g; children: 50 mg/kg PO 1 h before procedure
Unable to take oral medication
Ampicillin
Adults: 2.0 g IM or IV; children: 50 mg/kg IM or IV within 30 min before procedure
Penicillin-allergic
Clindamycinor
Adults: 600 mg; children: 20 mg/kg PO 1 h before procedure
Cephalexinor
Adults: 2.0 g; children: 50 mg/kg PO 1 h before procedure
Cefadroxil or
Adults: 2.0 g; children: 50 mg/kg PO 1 h before procedure
Azithromycinor
Adults: 500 mg; children: 15 mg/kg PO 1 h before procedure
Clarithromycin
Adults: 500 mg; children: 15 mg/kg PO 1 h before procedure
Penicillin-allergic and unable to take oral medications
Clindamycinor
Adults: 600 mg; children:20 mg/kg IV within 30 min before procedure
Cefazolinb
Adults: 1.0 g; children:25 mg/kg IM or IV within 30 min before procedure

recommendations by the American Heart

Association.

Antibiotic Prophylaxis Regimens for Genitourinary or

Gastrointestinal
(Excluding Esophageal) Procedures

High-risk patients
Ampicillin plus gentamicin
Adults: ampicillin 2.0 g IM/IV plus gentamicin 1.5 mg/kg (not to exceed 120 mg)
within 30 min of starting the procedure. Six hours later, ampicillin 1 g IM/IV or
amoxicillin 1 g PO.
Children: ampicillin 50 mg/kg IM or IV (not to exceed 2.0 g) plus gentamicin 1.5
mg/kg within 30 min of starting the procedure. Six hours later, ampicillin 25
mg/kg IM/IV or amoxicillin 25 mg/kg PO.
High-risk patients allergic to ampicillin/amoxicillin
Vancomycin plus gentamicin
Adults: vancomycin 1.0 g IV over 12 h plus gentamicin 1.5 mg/kg IV/IM (not to
exceed 120 mg). Complete injection/infusion within 30 min of starting the
procedure.
Children: vancomycin 20 mg/kg IV over 12 h plus gentamicin 1.5 mg/kg IV/IM.
Complete the injection/infusion within 30 min of starting the procedure.
Moderate-risk patients
Amoxicillin or ampicillin
Adults:amoxicillin 2.0 g PO 1 h before procedure, or ampicillin 2.0 g IM/IV within
30 min of starting the procedure.
Children: amoxicillin 50 mg/kg PO 1 h before procedure, or ampicillin 50 mg/kg
IM/IV within 30 min of starting the procedure.
Moderate-risk patients allergic to ampicillin/amoxicillin
recommendations by the American Heart
Vancomycin
Association. Circulation 1997;96:35866.

recommendations by the American Heart

Association. Circulation 2007

recommendations by the American Heart

Association. Circulation 2007