Medical treatment of elderly mitral stenosis patients
Recommendation	Grade of recommendation	Level of evidence
Regardless of severity, MS patients who have AF, be it permanent, persistent, or paroxysmal, should receive warfarin indefinitely, with the aim of keeping INR between 2 and 3, unless this is contraindicated	I	B
MS patients indicated for warfarin may use direct oral anticoagulants	IIb	C
Elderly rheumatic MS patients should receive prophylaxis to prevent rheumatic fever	III	C
Elderly MS patients with MVA less than or equal to 1.5 cm2; FC II, III, or IV; and/or signs of RVF should receive loop diuretics to alleviate symptoms	I	C
Elderly MS patients with MVA less than or equal to 1.5 cm2; FC II, III, or IV; and SR, who continue to be symptomatic in spite of diuretic use, if HR is over 60 bpm, should receive beta-blockers, unless there are contraindications	IIa	B
Elderly patients with mild MS who develop AF with elevated ventricular response should receive beta-blockers to control ventricular response, unless there are contraindications	IIa	C
In the previously described cases, nondihydropyridine calcium channel blockers or digitalis may be used, in the event that beta-blockers are contraindicated	IIa	C
MS patients with signs of RVF and hepatomegaly, without adequate response to loop diuretics, should receive spironolactone.	IIb	C

AF: atrial fibrillation; bpm: beats per minute; FC: New York Heart Association functional class; HR: heart rate; INR: international normalized ratio; MS: mitral stenosis; MVA: mitral valve area; RVF: right ventricle failure; SR: sinus rhythm.