ACC/AHA 2008 Guideline Update on Valvular Heart Disease: Focused Update on Infective Endocarditis: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic SurgeonsFree Access

2006 Writing Committee Members

Robert O. Bonow, MD, MACC, FAHA, Chair

Blase A. Carabello, MD, FACC, FAHA

Kanu Chatterjee, MB, FACC

Antonio C. de Leon, Jr, MD, FACC, FAHA

David P. Faxon, MD, FACC, FAHA

Michael D. Freed, MD, FACC, FAHA

William H. Gaasch, MD, FACC, FAHA

Bruce W. Lytle, MD, FACC, FAHA

Rick A. Nishimura, MD, FACC, FAHA

Patrick T. O'Gara, MD, FACC, FAHA

Robert A. O'Rourke, MD, MACC, FAHA

Catherine M. Otto, MD, FACC, FAHA

Pravin M. Shah, MD, MACC, FAHA

Jack S. Shanewise, MD^⁎

Task Force Members

Sidney C. Smith, Jr, MD, FACC, FAHA, Chair

Alice K. Jacobs, MD, FACC, FAHA, Vice-Chair

Christopher E. Buller, MD, FACC

Mark A. Creager, MD, FACC, FAHA

Steven M. Ettinger, MD, FACC

Harlan M. Krumholz, MD, FACC, FAHA

Frederick G. Kushner, MD, FACC, FAHA

Bruce W. Lytle, MD, FACC, FAHA†

Rick A. Nishimura, MD, FACC, FAHA

Richard L. Page, MD, FACC, FAHA

Lynn G. Tarkington, RN

Clyde W. Yancy, Jr, MD, FACC, FAHA

Table of contents

Preamble

A primary challenge in the development of clinical practice guidelines is keeping pace with the stream of new data upon which recommendations are based. In an effort to respond more quickly to new evidence, the American College of Cardiology/American Heart Association (ACC/AHA) Task Force on Practice Guidelines has created a new “focused update” process to revise the existing guideline recommendations that are affected by the evolving data or opinion. Prior to the initiation of this focused approach, periodic updates and revisions of existing guidelines required up to 3 years to complete. Now, however, new evidence will be reviewed in an ongoing fashion to more efficiently respond to important science and treatment trends that could have a major impact on patient outcomes and quality of care. Evidence will be reviewed at least twice a year, and updates will be initiated on an as needed basis as quickly as possible, while maintaining the rigorous methodology that the ACC and AHA have developed during their more than 20 years of partnership.

These updated guideline recommendations reflect a consensus of expert opinion after a thorough review primarily of late-breaking clinical trials identified through a broad-based vetting process as important to the relevant patient population, and of other new data deemed to have an impact on patient care (see Section 1.1 “Evidence Review” for details regarding this focused update). It is important to note that this focused update is not intended to represent an update based on a full literature review from the date of the previous guideline publication. Specific criteria/considerations for inclusion of new data include:

In analyzing the data and developing updated recommendations and supporting text, the focused update writing group used evidence-based methodologies developed by the ACC/AHA Task Force on Practice Guidelines, which are described elsewhere (1).

The schema for class of recommendation and level of evidence is summarized in Table 1, which also illustrates how the grading system provides an estimate of the size of the treatment effect and an estimate of the certainty of the treatment effect. Note that a recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in guidelines do not lend themselves to clinical trials. Although randomized trials may not be available, there may be a very clear clinical consensus that a particular test or therapy is useful and effective. Both the class of recommendation and level of evidence listed in the focused updates are based on consideration of the evidence reviewed in previous iterations of the guideline as well as the focused update. Of note, the implications of older studies that have informed recommendations but have not been repeated in contemporary settings are carefully considered.

Table 1. Applying Classification of Recommendations and Level of Evidence

The ACC/AHA practice guidelines address patient populations (and health care providers) residing in North America. As such, drugs that are not currently available in North America are discussed in the text without a specific class of recommendation. For studies performed in large numbers of subjects outside of North America, each writing committee reviews the potential impact of different practice patterns and patient populations on the treatment effect and on the relevance to the ACC/AHA target population to determine whether the findings should inform a specific recommendation.

The ACC/AHA practice guidelines are intended to assist health care providers in clinical decision making by describing a range of generally acceptable approaches for the diagnosis, management, and prevention of specific diseases or conditions. The guidelines attempt to define practices that meet the needs of most patients in most circumstances. The ultimate judgment regarding care of a particular patient must be made by the health care provider and patient in light of all the circumstances presented by that patient. Thus, there are circumstances in which deviations from these guidelines may be appropriate. Clinical decision making should consider the quality and availability of expertise in the area where care is provided. These guidelines may be used as the basis for regulatory or payer decisions, but the ultimate goal is quality of care and serving the patient's best interests.

Prescribed courses of treatment in accordance with these recommendations are only effective if they are followed by the patient. Because lack of patient adherence may adversely affect treatment outcomes, health care providers should make every effort to engage the patient in active participation with prescribed treatment.

The ACC/AHA Task Force on Practice Guidelines makes every effort to avoid any actual, potential, or perceived conflict of interest arising from industry relationships or personal interests of a writing committee member. All writing committee members and peer reviewers were required to provide disclosure statements of all such relationships pertaining to the trials and other evidence under consideration (see Appendixes 1 and 2). Final recommendations were balloted to all writing committee members. Writing committee members with significant (greater than $10000) relevant relationships with industry were required to recuse themselves from voting on that recommendation. Writing committee members who did not participate are not listed as authors of this focused update.

With the exception of the recommendations presented here, the full guideline remains current. Only the recommendations from the affected section(s) of the full guideline are included in this focused update. For easy reference, all recommendations from any section of a guideline impacted by a change are presented with notation as to whether they remain current, are new, or have been modified. When evidence impacts recommendations in more than 1 set of guidelines, those guidelines are updated concurrently.

The recommendations in this focused update will be considered current until they are superseded by another focused update or the full-text guidelines are revised. This focused update is published in the August 19, 2008, issue of the Journal of the American College of Cardiology and the August 19, 2008, issue of Circulation as an update to the full-text guideline, and is also posted on the ACC ( www.acc.org) and AHA ( www.americanheart.org) Web sites. A revised version of the 2006 full-text guideline that incorporates the focused update is available on the respective Web sites (2). For easy reference, this online-only version denotes sections that have been updated.

Sidney C. Smith, Jr, MD, FACC, FAHA

Chair, ACC/AHA Task Force on Practice Guidelines

Alice K. Jacobs, MD, FACC, FAHA

Vice-Chair, ACC/AHA Task Force on Practice Guidelines

1 Introduction

6 Management of Congenital Valvular Heart Disease in Adolescents and Young Adults

Antibiotic prophylaxis is no longer indicated in the adolescent and young adult with native heart valve disease for prevention of infective endocarditis.

Staff

American College of Cardiology Foundation

John C. Lewin, MD, Chief Executive Officer

Charlene May, Senior Director, Science and Clinical Policy

Lisa Bradfield, Associate Director, ACC/AHA Guidelines

Mark D. Stewart, MPH, Associate Director, Evidence-Based Medicine

Kennedy Elliott, Specialist, ACC/AHA Guidelines

Erin A. Barrett, Senior Specialist, Science and Clinical Policy

American Heart Association

M. Cass Wheeler, Chief Executive Officer

Gayle R. Whitman, RN, PhD, FAAN, FAHA, Vice President, Office of Science Operations

Kathryn A. Taubert, PhD, FAHA, Senior Science Advisor

Society of Cardiovascular Anesthesiologists Representative