Medication Summary
The goals of pharmacotherapy are to reduce morbidity and to prevent complications.
Diuretics
Class Summary
Help decrease pulmonary congestion.
Furosemide (Lasix)
Increases excretion of water by interfering with chloride-binding cotransport system, which, in turn, inhibits sodium and chloride reabsorption in the ascending loop of Henle and distal renal tubule. Dose must be individualized to patient.
Angiotensin-Converting Enzyme Inhibitors
Class Summary
Used in the presence of MR for afterload reduction.
Captopril (Capoten)
Competitive inhibitor of ACE. Reduces angiotensin II levels, decreasing aldosterone secretion. Goal is to decrease afterload to left ventricle (by reducing systemic blood pressure and by peripheral vasodilatation), which decreases amount of blood pumped by left ventricle and pressure at which blood is being ejected. This reduces amount of blood regurgitated by mitral valve from the left ventricle into the left atrium during systole. Elimination of drug is primarily by renal excretion. Impaired renal function requires dosage reduction. Absorbed well PO. Give at least 1 h before meals. If added to water, use within 15 min.
Enalapril (Vasotec)
Competitive inhibitor of ACE. Reduces angiotensin II levels, decreasing aldosterone secretion. Goal is to decrease afterload to left ventricle (by reducing systemic blood pressure and by peripheral vasodilatation), which decreases amount of blood being pumped by left ventricle and pressure at which blood is being ejected. This reduces amount of blood regurgitated by the mitral valve from left ventricle into left atrium during systole.
Lisinopril (Zestril, Prinivil)
Prevents conversion of angiotensin I to angiotensin II, a potent vasoconstrictor, resulting in lower aldosterone secretion.
Nitrates
Class Summary
Used for decreasing blood pressure and increasing coronary blood flow.
Nitroglycerin IV (Deponit, Nitro-Bid, Nitrostat, Nitrol)
Causes relaxation of vascular smooth muscle by stimulating intracellular cyclic guanosine monophosphate production. Result is decrease in blood pressure.
Inotropic Agents
Class Summary
Because of its antiarrhythmic properties, digoxin is used if atrial fibrillation is encountered; however, it is not expected to improve overall cardiac function.
Digoxin (Lanoxin)
Cardiac glycoside with direct inotropic effects in addition to indirect effects on cardiovascular system. Acts directly on cardiac muscle, increasing myocardial systolic contractions. Indirect actions result in increased carotid sinus nerve activity and enhanced sympathetic withdrawal for any given increase in mean arterial pressure.
Digitalizing dose is approximately 20% less than PO dose. IM injection offers no advantage and can cause severe pain at injection site. IV is preferred. IV digoxin begins to have effect after 15-30 min and peaks in 1.5-3 h.
Antibiotics, Prophylactic
Class Summary
Provide subacute bacterial endocarditis prophylaxis. Use prior to any interventional therapy to protect the diseased valves.
Cephalexin (Keflex)
First-generation cephalosporin that inhibits bacterial replication by inhibiting bacterial cell wall synthesis. Bactericidal and effective against rapidly growing organisms forming cell walls.
Resistance occurs by alteration of penicillin-binding proteins. Effective for treatment of infections caused by streptococcal or staphylococci, including penicillinase-producing staphylococci. May use to initiate therapy when streptococcal or staphylococcal infection is suspected.
Used orally when outpatient management is indicated.
Ampicillin (Marcillin, Omnipen)
For prophylaxis in patients undergoing dental, oral, or respiratory tract procedures. Coadministered with gentamicin for prophylaxis in GI or GU procedures.
Amoxicillin (Amoxil, Trimox)
Interferes with synthesis of cell wall mucopeptides during active multiplication, resulting in bactericidal activity against susceptible bacteria. Used as prophylaxis in minor procedures.
Clindamycin (Cleocin)
Used in patients who are allergic to penicillin and are undergoing dental, oral, or respiratory tract procedures. Useful for treatment against streptococcal and most staphylococcal infections.
Gentamicin (Garamycin)
Aminoglycoside antibiotic for gram-negative coverage. Used in combination with both an agent against gram-positive organisms and one that covers anaerobes. Used in conjunction with ampicillin or vancomycin for prophylaxis in GI and GU procedures.
Vancomycin (Vancocin)
Potent antibiotic directed against gram-positive organisms and active against enterococcal species. Useful in treatment of septicemia and skin structure infections. Indicated for patients who cannot receive, or have not responded to, penicillins and cephalosporins or who have infections with resistant staphylococci.
Use CrCl to adjust dose in patients diagnosed with renal impairment.
Used in conjunction with gentamicin for prophylaxis in patients who are allergic to penicillin and are undergoing GI or GU procedures.
Erythromycin (EES, E-Mycin, Eryc)
Used for prophylaxis in patients who are allergic to penicillin and are undergoing dental, oral, or respiratory tract procedures.
Azithromycin (Zithromax)
Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes, causing RNA-dependent protein synthesis to arrest.
Clarithromycin (Biaxin)
Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest.
Cefazolin (Ancef)
First-generation semisynthetic cephalosporins that arrest bacterial cell wall synthesis, inhibiting bacterial growth. Primarily active against skin flora, including Staphylococcus aureus.
Cefadroxil (Duricef)
First generation semi-synthetic cephalosporin, that arrests bacterial growth by inhibiting bacterial cell wall synthesis. Bactericidal activity against rapidly growing organisms. Primarily active against skin flora, including Staphylococcus aureus.
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Transthoracic echocardiogram demonstrating severe mitral regurgitation with heavily calcified mitral valve and prolapse of the posterior leaflet into the left atrium.
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Transesophageal echocardiogram demonstrating prolapse of both mitral valve leaflets during systole.
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Transthoracic echocardiogram demonstrating bioprosthetic mitral valve dehiscence with paravalvular regurgitation.
Tables
Stage |
Valve Anatomy |
Valve Hemodynamics* |
Hemodynamic Consequences |
Symptoms |
A: Primary MR |
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A: Secondary MR |
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B: Primary MR |
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B: Secondary MR |
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C: Primary MR |
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C: Secondary MR |
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D: Primary MR |
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D: Secondary MR |
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*Several criteria are provided but not all criteria for each category will be present. Severity of mild, moderate, or serve is dependent on data quality and integration with other clinical evidence. †In secondary MR, true ERO is underestimated due to the crescentic shape of the proximal convergence |
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CAD = coronary heart disease; ERO = effective regurgitation orifice; HF = heart failure; IE = infective endocarditis; LA = left atrium; LV = left ventricular; LVEF = left ventricular ejection factor; LVESD = left ventricular end-systolic dimension; MR = mitral regurgitation; MV = mitral valve; TTE = transthoracic echocardiography. |
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