Valvular heart disease : Role of medication ( drug and intervention ) Pol.Col.Dr.Kasem Ratanasumawong
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1 Valvular heart disease : Role of medication ( drug and intervention ) Pol.Col.Dr.Kasem Ratanasumawong
2 Management of valvular heart disease Accurate diagnosis and disease severity Prevention and treatment of complication Monitor and consider timing of surgery ( wait and watch ) Assess and treatment of comorbidity and associated condition
3 Role of medications Prevention of complication Treatment of complication Symptomatic treatment General health care Treatment of co-existent disease Prevention of disease progression : delayed surgical treatment
4 Complication of valvular heart disease Infective endocarditis Recurrent rheumatic fever Thromboembolism Disease progression -> heart failure
5 Case study 1 A 40 year old female patient with severe MS with Dyspnea on exertion. BP 110/80 mmhg, HR 120/min, irregular pulse Echo : Thickened and doming of MV MVA 0.8cm.2by pressure half time no LA thrombus What is your management?
6 Prevention of endocarditis 2008 focused update ACC/AHA guideline management of valvular heart disease
7 Prevention of endocarditis
8 Secondary rheumatic prophylaxis Statement for health professionals, AHA 1995
9 Prevention of rheumatic fever
10 Risk of thromboembolism in valvular heart disease Systemic embolization may occur in 10-20% of patients with MS Risk related to age and present of AF AF with MS : highest risk among native valve AF with MR, aortic valve and tricuspid valve : relatively lower risk
11 Thai guideline of oral anticoagulant 2010 New oral anticoagulants is not recommended
12 Prevention of thromboembolism Mitral stenosis 2008 focused update ACC/AHA guideline management of valvular heart disease
13 Symptomatic MS Mitral stenosis Loop diuretics Beta blocker, rate slowing calcium blocker Digoxin ACE inhibitor or vasodilator : not recommended
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15 Management of mitral stenosis
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18 Symptomatic MR Mitral regurgitation Acute or chronic Acute setting Sodium nitroprusside / Dobutamine Chronic setting Diuretic, vasodilator, ACE inhibitor, Beta blocker indicate in IHD, LV dysfunction or HT
19 Medical treatment in MR No indication for vasodilator and ACE inhibitors in asymptomatic patients with MR and preserved LV function ACE inhibitor and beta blocker indicate in patient with HT, LV dysfunction from functional or ischemic MR If presence of AF : calcium antagonist, beta blocker, digoxin or amiodarone and anticoagulant IE prophylaxis : no longer recommend
20 Symptomatic AR 2008 focused update ACC/AHA guideline management of valvular heart disease
21 Progression to AVR in asymptomatic severe AR Evangelista A,et al. N Engl J Med 2005; 353:
22 Symptomatic AS Aortic stenosis Diuretic : relieve pulmonary congestion, over diuresis -> hypotension Vasodilator : use carefully Inotropic drug : in cardiogenic shock Treatment should be guided by invasive monitoring in cardiogenic shock with prompt surgery
23 Medical treatment in AS AS with HT,CAD Low dose diuretic, beta blocker, ACE inhibitor,arb can be used Precaution when increase dose Nitrates sublingual must be carefully
24 Statin in aortic stenosis Roseboro AB et al, N Engl J Med 2008; 359:
25 Case study 2 A 80 year old male patient with symptomatic severe AS BP 110/80 mmhg, HR 90/min with pulsus parvus et tardus What is your management?
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27 TAVI
28 TAVI
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37 Take home message (1) No specific medical treatment to prevent progression of native valves disease Antithrombotic treatment is essential to prevent thromboembolism esp. mitral valve disease Rheumatic prophylaxis Endocarditis prophylaxis : no longer recommended
38 Take home message (2) Concomitant medical treatment of coexistent disease General health care eg. immunization, daily activity Establish schedule of clinical and echo follow up Wait and watch : timing of intervention and surgery
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