Prophylaxis Of Rheumatic Fever Research Articles

Seven year follow up of subclinical rheumatic disease using WHF criteria

Abstract Background The prevalence of rheumatic heart disease (RHD) is higher using echocardiographic screening compared with clinical examination. It is proven that clinical screening underestimates the prevalence, but it still remains the cornerstone for the purpose of intervention. Echocardiography can identify subclinical RHD and can be used for subclinical cases and to see progression /regression on follow up. Follow-up data of children with subclinical lesions are very much needed before implementing large scale screening programs in endemic regions. We are submitting the 7 year follow up data for subclinical RHD who were on RF prophylaxis. Method A total of 3000 school going children were screened echocardiographically during November 2015 to December 2018 for subclinical rheumatic heart disease using WHF criteria. Subjects with subclinical rheumatic heart disease were given prophylaxis for rheumatic fever in form of injection Benzathine penicillin or oral penicillin or tablet erythromycin depending upon tolerance and acceptance. These cases were followed up at 2-year and 7-year for echocardiographic evaluation and compliance to the prophylaxis. Results Out of 3000 cases screened, 114 were found to be having subclinical rheumatic heart disease. 39 subjects turned up for 2-year follow up and 13 subjects turned up for 7-year follow up(Table 1). All 13 were on rheumatic fever prophylaxis. 23% ( 3 out of 13) turned to be with normal echocardiography findings using WHF 2012 criteria. Limitation: Children who were not taking prophylaxis were not evaluated echocardiographically, therefore comparison could not be done. Conclusion Our study shows screening of school going children by echocardiography can detect subclinical rheumatic heart disease and rheumatic fever prophylaxis in such cases can results in reversion of the lesion and prevention of progression of RHD.

Knowledge, attitude, and experiences of using penicillin G, as a prophylaxis for rheumatic fever and rheumatic heart diseases among nurses in Addis Ababa, Ethiopia: A cross-sectional survey

Knowledge, attitude, and experiences of using penicillin G, as a prophylaxis for rheumatic fever and rheumatic heart diseases among nurses in Addis Ababa, Ethiopia: A cross-sectional survey

Adherence rates and risk factors for suboptimal adherence to secondary prophylaxis for rheumatic fever.

AimSecondary prophylaxis with 3–4 weekly benzathine penicillin G injections is necessary to prevent disease morbidity and cardiac mortality in patients with acute rheumatic fever (ARF) and rheumatic heart disease (RHD). This study aimed to determine secondary prophylaxis adherence rates in the Far North Queensland paediatric population and to identify factors contributing to suboptimal adherence.MethodsA retrospective analysis of data recorded in the online RHD register for Queensland, Australia, was performed for a 10‐year study period. The proportion of benzathine penicillin G injections delivered within intervals of ≤28 days and ≤35 days was measured. A multi‐level mixed model logistic regression assessed the influence of age, gender, ethnicity, suburb, Accessibility and Remoteness Index of Australia class, number of people per dwelling, Index of Relative Socio‐economic Advantage and Disadvantage, Index of Education and Occupation, year of inclusion on an ARF/RHD register and individual effect.ResultsThe study included 277 children and analysis of 7374 injections. No children received ≥80% of recommended injections within a 28‐day interval. Four percent received ≥50% of injections within ≤28 days and 46% received ≥50% of injections at an extended interval of ≤35 days. Increasing age was associated with reduced delivery of injections within 35 days. Increasing year of inclusion was associated with improved delivery within 28 days. The random effect of individual patients was significantly associated with adherence.ConclusionsImproved timely delivery of secondary prophylaxis for ARF and RHD is needed as current adherence is very low. Interventions should focus on factors specific to each individual child or family unit.

Colchicine ameliorates the chronic inflammatory state in patients with chronic rheumatic valvular heart disease: a pilot study

BackgroundInflammation is an important contributor to the pathogenesis of rheumatic heart disease (RHD). High serum levels of C-reactive protein (CRP) and interleukin-6 (IL-6) are commonly seen in patients with chronic (RHD) and indicate the presence of a chronic inflammatory state. The aim of this study was to assess the effect of colchicine as anti-inflammatory drug on the serum levels of the inflammatory markers (CRP) and (IL-6) in patients with chronic (RHD).ResultsThis is a prospective controlled study that enrolled thirty-five patients with chronic (RHD) visiting Ain Shams University Hospital’s outpatient clinic for receiving regular long acting penicillin as rheumatic fever prophylaxis. Ten matched healthy individuals were taken as control group. Blood samples for serum levels of CRP and IL-6 were collected before and 1 month after receiving colchicine 0.5 mg BID. Mean (CRP) level was 6.09 ± 4.39 IU/ml versus 0 IU/ml in the control group respectively (P = 0.0001). Mean (IL-6) level was 113.57 ± 37.41 ng/l versus 10.50 ± 5.99 ng/l, in the control group (p = 0.0001). Mean (CRP) was 6.09 ± 4.39 IU/ml before and became 3.34 ± 3.07I U/ml 1 month after colchicine therapy. Mean (IL-6) level was 113.57 ± 37.4 ng/l before and became 45.57 ± 20.39 ng/l 1 month after colchicine therapy (P = 0.001).ConclusionIn this pilot study, using colchicine as anti-inflammatory drug in patients with chronic (RHD) significantly reduced the serum inflammatory markers (CRP) and (IL-6), thus helping in ameliorating their chronic inflammatory state.

Mismatches between health service delivery and community expectations in the provision of secondary prophylaxis for rheumatic fever in New Zealand

ObjectiveRheumatic fever (RF) recurrence prevention requires secondary prophylaxis for at least ten years. However, recurrences of rheumatic fever (RRF) persist disproportionately affecting Māori and Pacific youth. Reasons for recurrence rates are not well understood and commonly attributed to patient non‐adherence. This research explored Māori and Pacific family experiences of RRF to better understand barriers to accessing secondary prophylaxis to inform health service improvements. MethodsParticipants were Māori and Pacific patients who had RRF or unexpected rheumatic heart disease and their family; and health professionals working in RF contexts. Kaupapa Māori, Talanga and Kakala Pacific qualitative methodologies were employed. Data were thematically analysed using a general inductive approach. ResultsData collection included 38 interviews with patients and families (n=80), six focus group interviews and nine interviews with health providers (n=33) from seven geographic regions. Three key themes were identified where mismatches occurred between services and community needs: 1. Model of delivery; 2. Interpersonal approaches to care; and 3. Adolescent care. Conclusions and Public health implicationsSuccessful RRF prevention requires interventions to address structural causes of inequity, appropriate clinical guidelines and quality health services. Service‐delivery models should provide regular prophylaxis in an accessible manner through culturally‐safe, community‐based, age‐appropriate care.

Post streptococcal reactive arthritis in children: varied presentations, differentiationfrom acute rheumatic fever and antibiotic prophylaxis

Post streptococcal reactive arthritis in children: varied presentations, differentiationfrom acute rheumatic fever and antibiotic prophylaxis

Enablers and barriers to secondary prophylaxis for rheumatic fever among M\u0101ori aged 14\u201321 in New Zealand: a framework method study

BackgroundAcute rheumatic fever (ARF) rates have declined to near zero in nearly all developed countries. However, in New Zealand rates have not declined since the 1980s. Further, ARF diagnoses in New Zealand are inequitably distributed--occurring almost exclusively in Māori (the indigenous population) and Pacific children--with very low rates in the majority New Zealand European population. With ARF diagnosis, secondary prophylaxis is key to prevent recurrence. The purpose of this study was to identify the perceived enablers and barriers to secondary recurrence prophylaxis following ARF for Māori patients aged 14–21.MethodsThis study took a systems approach, was informed by patient voice and used a framework method to explore potential barriers and enablers to ongoing adherence with monthly antibiotic injections for secondary prophylaxis. Qualitative interviews were conducted with 19 Māori ARF patients receiving recurrence prophylaxis in the Waikato District Health Board region. Participants included those fully adherent to treatment, those with intermittent adherence or those who had been “lost to follow-up.”ResultsBarriers and enablers were presented around three factors: system (including access/resources), relational and individual. Access and resources included district nurses coming to patients as an enabler and lack of income and time off work as barriers. Relational characteristics included support from family and friends as enablers and district nurse communication as predominantly a positive although not enabling factor. Individual characteristics included understanding, personal responsibility and fear/pain of injections.ConclusionThis detailed exploration of barriers and enablers for ongoing secondary prophylaxis provides important new information for the prevention of recurrent ARF. Among other considerations, a national register, innovative engagement with youth and their families and a comprehensive pain management programme are likely to improve adherence to ongoing secondary prophylaxis and reduce the burden of RHD for New Zealand individuals, families and health system.

Adherence to Secondary Prophylaxis for Acute Rheumatic Fever and Rheumatic Heart Disease: A Systematic Review.

Background:Optimal delivery of regular benzathine penicillin G (BPG) injections pre-scribed as secondary prophylaxis for acute rheumatic fever (ARF) and rheumatic heart disease (RHD) is vital to preventing disease morbidity and cardiac sequelae in affected pediatric and young adult popu-lations. However, poor uptake of secondary prophylaxis remains a significant challenge to ARF/RHD control programs.Objective:In order to facilitate better understanding of this challenge and thereby identify means to improve service delivery, this systematic literature review explored rates of adherence and factors asso-ciated with adherence to secondary prophylaxis for ARF and RHD worldwide.Methods:MEDLINE was searched for relevant primary studies published in the English language from 1994-2014, and a search of reference lists of eligible articles was performed. The methodological quality of included studies was evaluated using a modified assessment tool.Results:Twenty studies were included in the review. There was a range of adherence to varying regi-mens of secondary prophylaxis reported globally, and a number of patient demographic, clinical, socio-cultural and health care service delivery factors associated with adherence to secondary prophylaxis were identified.Conclusion:Insights into factors associated with lower and higher adherence to secondary prophylaxis may be utilized to facilitate improved delivery of secondary prophylaxis for ARF and RHD. Strategies may include ensuring an effective active recall system, providing holistic care, involving community health workers and delivering ARF/RHD health education.

Preliminary consultation on preferred product characteristics of benzathine penicillin G for secondary prophylaxis of rheumatic fever

Rheumatic fever is caused by an abnormal immune reaction to group A streptococcal infection. Secondary prophylaxis with antibiotics is recommended for people after their initial episode of rheumatic fever to prevent recurrent group A streptococcal infections, recurrences of rheumatic fever and progression to rheumatic heart disease. This secondary prophylaxis must be maintained for at least a decade after the last episode of rheumatic fever. Benzathine penicillin G is the first line antibiotic for secondary prophylaxis, delivered intramuscularly every 2 to 4weeks. However, adherence to recommended secondary prophylaxis regimens is a global challenge. This paper outlines a consultation with global experts in rheumatic heart disease on the characteristics of benzathine penicillin G formulations which could be changed to improve adherence with secondary prophylaxis. Characteristics included dose interval, pain, administration mechanism, cold chain independence and cost. A sample target product profile for reformulated benzathine penicillin G is presented.

PT297 Brazilian Shortage Crisis of Benzathine Penicillin G and Rheumatic Fever Prophylaxis

PT297 Brazilian Shortage Crisis of Benzathine Penicillin G and Rheumatic Fever Prophylaxis

Amoxicillin for the secondary prevention of rheumatic fever in children not allergic to penicillin

Amoxicillin for the secondary prevention of rheumatic fever in children not allergic to penicillin To the Editor: In October 2014, a communication from the Department of Health substituted azithromycin for erythromycin for penicillin-allergic patients. This was for certain conditions including acute rheumatic fever and prophylaxis of rheumatic fever. It has recently been suggested that owing to the challenges with the availability of oral penicillin, azithromycin should be used as a penicillin substitute for patients who are not allergic to penicillin. In our opinion it is inappropriate to substitute a macrolide for another form of penicillin (amoxicillin) in this situation. The primary reason is that despite many decades of use, there is no significant group A beta-haemolytic streptococcal (GABHS) resistance to penicillin. There are, however, increasing reports of GABHS resistance to macrolides, and azithromycin in particular.[1-4] A previously reported randomised trial[5] of 125 mg phenoxymethylpenicillin (pen VK) or amoxicillin given three times a day for 10 days to children with GABHS pharyngitis demonstrated that the recurrence of the original GABHS within 21 days after the end of therapy was higher with pen VK (20%) than with amoxicillin (13%). The geometric mean minimum inhibitory concentrations for amoxicillin and pen VK against 88 isolates of GABHS were 0.008 and 0.009 μg/mL, respectively. The mean concentrations of amoxicillin and pen VK in sera after 125 mg doses were 3.86 μg/ mL and 1.74 μg/ mL, respectively. In this study, therefore, amoxicillin was active against Gram-positive organisms at an inhibitory level similar to that of pen VK, but had higher blood levels. This study suggests that amoxicillin is probably at least as good as pen VK for the treatment of GABHS pharyngitis. We therefore recommend, as per the South African Essential Drugs List, benzathine penicillin 600 000 units for children <30 kg and 1.2 million units for children ≥30 kg by intramuscular injection every 28 days for the secondary prevention of rheumatic fever. If it is not advisable to use an intramuscular form of penicillin (for example with a patient on warfarin), then in the absence of pen VK and in the absence of penicillin allergy, children weighing <20 kg should be given amoxicillin 125 mg twice daily, and children weighing ≥20 kg given 250 mg twice daily. There is no defined azithromycin paediatric dosage for the secondary prevention of rheumatic fever in penicillin allergy. Azithromycin has however been dosed long term in clinical trials in children with cystic fibrosis.[6-8] There is no consensus on the dosage, but there is some support[6-9] for 250 mg once daily (<40 kg) or 500 mg once daily (≥40 kg) three times a week (Monday, Wednesday and Friday). We recommend that azithromycin is used for the secondary prevention of rheumatic fever only in children who are allergic to penicillin and is dosed 250 mg (<40 kg) or 500 mg (≥40 kg), once a day three times a week (Monday, Wednesday and Friday).

Amoxicillin for the secondary prevention of rheumatic fever in children not allergic to penicillin

To the Editor: In October 2014, a communication from the Department of Health substituted azithromycin for erythromycin for penicillin-allergic patients. This was for certain conditions including acute rheumatic fever and prophylaxis of rheumatic fever. It has recently been suggested that owing to the challenges with the availability of oral penicillin, azithromycin should be used as a penicillin substitute for patients who are not allergic to penicillin.

Approaches to Improving Adherence to Secondary Prophylaxis for Rheumatic Fever and Rheumatic Heart Disease: A Literature Review with a Global Perspective.

Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) are autoimmune conditions resulting from infection with group A streptococcus. Current management of these conditions includes secondary antibiotic prevention. This comprises regular 3 to 4 weekly long-acting intramuscular benzathine penicillin injections. Secondary antibiotic prevention aims to protect individuals against reinfection with group A streptococcus, thereby preventing recurrent ARF and the risk of further damage to the heart valves. However, utilization of benzathine penicillin can be poor leaving patients at risk of avoidable and progressive heart damage. This review utilizes the Chronic Care Model as a framework to discuss initiatives to enhance the delivery of secondary antibiotic prophylaxis for ARF and RHD. Results from the search strategy utilized revealed that there is limited pertinent published evidence. The evidence that is available suggests that register/recall systems, dedicated health teams for delivery of secondary antibiotic prophylaxis, education about ARF and RHD, linkages with the community (particularly between health services and schools), and strong staff-patient relationships may be important. However, it is difficult to generalize findings from individual studies to other settings and high quality studies are lacking. Although secondary antibiotic prophylaxis is an effective treatment for those with ARF or RHD, the difficulties in implementing effective programs that reduce the burden of ARF and RHD demonstrates the importance of ongoing work in developing and evaluating research translation initiatives.

Infective endocarditis in Ethiopian children: a hospital based review of cases in Addis Ababa.

IntroductionInfective endocarditis is an infection of the endocardial lining of the heart mainly associated with congenital and rheumatic heart disease. Although it is a rare disease in children, it is associated with high morbidity and mortality; death due to infective endocarditis has been reported to be as high as 26% in sub-Saharan Africa.MethodsThis was a retrospective review of routinely collected data from patient records.ResultsA total of 40 children (71% female) with 41 episodes of infective endocarditis admitted to a general paediatric ward in Addis Ababa, Ethiopia between 2008 and 2013. Age ranged from 7 months to 14 years, with a median of 9 years (Inter quartile Range: 7-12 years). Rheumatic and congenital heart diseases were underlying risk factors in 49% and 51% of cases respectively. Congestive heart failure, systemic embolization and death occurred in 66%, 12% and 7.3% respectively. Death was associated with the occurrence of systemic embolization (P-value = 0.03).ConclusionRheumatic heart disease was an important predisposing factor for infective endocarditis in Ethiopian children. Late presentations of cases were evidenced by high proportion of complications such as congestive heart failure. A low rate of clinically evident systemic embolization in this study may be a reflection of the diagnostic challenges. High proportion of prior antibiotic intake might explain the cause of significant BCNE. Preventive measures like primary and secondary prophylaxis of rheumatic fever may decrease the associated morbidity and mortality. Early detection and referral of cases, awareness creation about indiscriminate use of antimicrobials, and proper history taking and documentation of information recommended.

KNOWLEDGE OF CARDIOLOGISTS RELATED TO PROPHYLAXIS OF RHEUMATIC FEVER IN SALVADOR- BA

Objective: Describe and analyze the knowledge of cardiologists on the prophylaxis of Rheumatic Fever (RF). Method: Application of questionnaire to cardiologists and cardiology residents March/2012 to December/2014. Results: The questionnaire was answered by 52 cardiologists 37 (71.8 %) specialists and 15 (28.9 %) cardiology residents. The average time for the formation of the group was 19.28 (±10.16) years, 39 (75 %) work in outpatient SUS, 34 (65%) in private practice. Of these 26 (50%) reported not having followed any cases of acute RF in the last year and 9 (17.3%) said they had not accompanied chronic RF cases last year. Among the 35 respondents (67.3%) report that they attended to most cases in the past and 37 (71.2 %) believe that there has been a decline in the disease. Although the majority, 47 (90.4 %) have knowledge about the last guideline of treatment and diagnosis of RF, the accuracy rate of all therapeutic options used in primary prophylaxis of these patients was 5 (9.6%) and secondary 7 (13.4 %), however 49 (94.2 %) made reference to benzathine penicillin as an option. Conclusions: The current study identified that, although RF is still an important clinical condition in our environment, the physicians interviewed did not show adequate knowledge on the subject, which could be related to poor patient adherence to RF prophylaxis. Greater attention should be devoted to continuing education on RF, which is a disease often neglected.

Low adherence to secondary prophylaxis among clients diagnosed with rheumatic fever, Jamaica

Objectives:To determine the level of adherence and possible barriers to secondary prophylaxis among clients with rheumatic fever in Kingston, Jamaica.Methods:Cross-sectional survey of 39 clients diagnosed with rheumatic fever, receiving penicillin prophylaxis for more than a year using a 22-item self-administered questionnaire on adherence to secondary prophylaxis and knowledge of rheumatic fever. The patients’ records were reviewed to determine the number of prophylaxis injections the patients received for the year 2010.Results:The majority of participants (74%) were females and 51% were adults. Only 48·7% had a high level of adherence. The majority (72%) had low knowledge levels regarding their illness, while only 5% had a high knowledge level score. Most clients (70%) strongly agreed that nurses and doctors encouraged them to take their prophylaxis. However, over 60% reported that they travelled long distances and or waited long periods to get their injections. One-third reported that they missed appointments because of fear of injections and having to take time off from work or school.Discussion:Clients attending the health centers studied had limited knowledge about rheumatic fever. Barriers to adherence included fear of the injections, long commutes, and long waiting periods at the facilities studied.

Allergic reaction to long – term Benzathine penicillin injection for secondary prevention of acute rheumatic fever and recommendations for skin testing

Background Rheumatic Fever (RF) causes 25-40% of all cardio vascular disease in developing countries. Long term benzathine penicillin injection is being used for secondary prophylaxis of RF / RHD. Although allergic reaction to penicillin is rare skin testing is performed routinely before each and every penicillin injection delivery in most of the hospitals in Nepal. Objectives Objectives of this study was to evaluate safety of long term benzathine penicillin injection and establish recommendations for penicillin skin testing. Methods Data from the registers of National RF/RHD prevention and control programme from 32 hospitals of Nepal were collected and analyzed in a retrospective study. Results 65 patients (1.4%) among 77300 injections of benzathine penicillin given to 4712 patients, had allergic reactions. 5 had anaphylaxis, an incidence of 0.1% (0.7/10000 injections), 60 had minor allergy, an incidence of 1.3%. Conclusions Life-threatening allergic reactions are very rare in patients on long-term intramuscular benzathine penicillin for secondary prevention of RF. With these rare complications, regular skin test before each and every benzathine penicillin injection delivery has no significant role. Nevertheless Skin testing is recommended before 1st injection and patients having different batch number and or brand name. DOI: http://dx.doi.org/10.3126/njh.v8i1.8331 Nepalese Heart Journal Vol.8(1) 2011 pp.16-18

Confirmed penicillin allergy among patients receiving benzathine penicillin prophylaxis for acute rheumatic fever

BackgroundBeta-lactam antibiotics are the most frequent drugs prescribed in children worldwide. Acute rheumatic fever (ARF) is the major cause of acquired heart disease among children and adolescents. Recurrences due to inadequate penicillin prophylaxis are responsible for chronic valvular lesions requiring surgery. The fear of a severe allergic reaction is the leading cause of discontinuing prophylaxis. ObjectiveIn this study, we aimed to reveal the frequency of adverse events and real allergic reactions to benzathine penicillin among children who are followed in our paediatric cardiology clinic with a diagnosis of ARF. Materials methodsThe children who were followed with a diagnosis of ARF between January 2005 and December 2011 were searched for a history of penicillin allergy. Patients with a positive history were evaluated in our paediatric allergy clinic. Skin tests and provocation tests were performed with parental consent. ResultsIn total 535 children with a diagnosis of ARF were analysed for the study. Median follow up period was 24 months (12–36) [median (%25–75)]. Eleven of our 535 (11/17.641 injection) ARF patients were suspected to have allergic reactions after 17.641 penicillin injections but only one (0.18%) was diagnosed to have penicillin allergy after detailed evaluation. ConclusionOur data suggest that the frequency of penicillin allergy is much lower than suspected among children on penicillin prophylaxis for ARF. Consequently, penicillin prophylaxis should not be given up without proper evaluation of drug allergy.

Efeito da penicilina G a cada três semanas sobre o surgimento de Streptococcus viridans resistentes à penicilina na microflora oral

Benzathine penicillin G every 3 weeks is the standard protocol for secondary prophylaxis for recurrent rheumatic fever. Assess the effect of Benzathine penicillin G on Streptococcus sanguinis and Streptococcus oralis in patients with cardiac valvular disease due to rheumatic fever receiving secondary prophylaxis. Oral streptococci were evaluated before (baseline) and after 7 days (day 7) with Benzathine penicillin G in 100 patients receiving routine secondary rheumatic fever prophylaxis. Saliva samples were evaluated for colony count and presence of S. sanguinis and S. oralis. Chewing-stimulated saliva samples were serially diluted and plated onto both nonselective and selective 5% sheep blood agar containing penicillin G. The species were identified using conventional biochemical tests. Minimal inhibitory concentrations were determined with the Etest. No statistical differences were found in the presence of S. sanguinis comparing baseline and day 7 (p = 0.62). However, the existing number of positive cultures of S. oralis on day 7 after Benzathine penicillin G presented a significant increase compared to baseline (p = 0.04). No statistical difference was found between baseline and day 7 concerning the number of S. sanguinis or S. oralis CFU/mL and median minimal inhibitory concentrations. This study showed that Benzathine penicillin G every 3 weeks did not change the colonization by S. sanguinis, but increased colonization of S. oralis on day 7 of administration. Therefore, susceptibility of Streptococcus sanguinis and Streptococcus oralis to penicillin G was not modified during the penicillin G routine secondary rheumatic fever prophylaxis.

Valvular Heart Disease: A Primer for the Clinical Pharmacist

Valvular heart disease is a commonly encountered clinical condition that is not taught in most undergraduate and graduate pharmacy programs, leaving the practicing pharmacist without basic knowledge to expand on and subsequently apply to direct patient care. Unlike other areas of cardiology in which thousands of patients are recruited in many well-designed randomized clinical trials, data assessing treatments for valvular heart disease are limited and often consist of retrospective case series or observations. Our goal is to provide a basic overview of chronic valvular heart disease, with emphasis on describing the common conditions requiring surgery and the available options, as well as common pharmacologic therapies used in this patient population. Anomalies in valves can be broadly classified as stenosis and regurgitation. Depending on the valve and the type of anomaly, the impact on the cardiovascular system will vary. Understanding the hemodynamic consequences of aortic stenosis, aortic regurgitation, mitral stenosis, and mitral regurgitation is imperative to effectively counsel patients surrounding disease progression and self-monitoring, use of vasodilators, and prophylaxis for endocarditis and rheumatic fever. Further, patient characteristics factored into the choice of implanting either a bioprosthetic (tissue) or prosthetic (metal) valve encompass patient choice, life expectancy, and willingness or ability to accept lifelong anticoagulation therapy. The evolution of metal valves has resulted in newer generations under clinical study that have more laminar flow (minimizing interaction with blood products) and improved pyrolytic carbon (minimizing infection and interaction with blood products). Although antithrombotic therapy with warfarin is now mandatory in North America for all patients receiving metal valves, research is ongoing to assess the need with the most recent generation of valves.