The ESC guidelines recommend prophylaxis for high risk patients undergoing the highest risk procedures.42 The patients at highest risk are those who have previously had endocarditis, those with a prosthetic valve, uncorrected or only partially corrected cyanotic congenital heart disease, corrected congenital heart disease in the first six months after surgery, and those with a residual defect at the site of prosthetic material. The highest risk procedures are “dental procedures requiring manipulation of the gingival or periapical region of the teeth or perforation of the oral mucosa” (which includes dental scaling). Amoxicillin or ampicillin are the recommended prophylactic antibiotics – clindamycin may be used in those with penicillin allergy.
Patients at high risk undergoing non-high risk procedures (such as bronchoscopy or colonoscopy) do not require antibiotic prophylaxis. Similarly, patients with non-high risk heart disease (such as mitral valve prolapse) undergoing high risk procedures should not receive antibiotic prophylaxis.
In contrast, the UK National Institute for Health and Clinical Excellence (NICE) recommends that antibiotic prophylaxis is not indicated for any patient in any situation. This controversial recommendation has the advantage of removing the uncertainty and variability between clinical practitioners in interpretation of the international guidelines (see figure 943). Nevertheless, the views of NICE are not supported by a significant number of cardiologists and cardiac surgeons.44 The sharp reduction in prophylactic antibiotic prescribing following the introduction of the NICE guidelines was accompanied by an increase in trend of incidence of endocarditis in the UK.45 In the absence of randomised trial evidence, this cotroversy is unlikely to be further clarified in the near future.
Conclusions
In this module we have discussed disease-modifying and supportive medical therapy for patients with VHD (see figure 10), indications for anticoagulation in patients with native VHD, and antibiotic prophylaxis of endocarditis. Disease-modifying treatments have not provided the anticipated clinical outcomes, while previous dogma around supportive therapy (such as the avoidance of vasodilators in patients with AS) has been recently challenged. Over the next decade, we hope that new evidence will enlighten our decision making in the pharmacological treatment of VHD.
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