. 2022 Jan 20;11(5):e024517. doi: 10.1161/JAHA.121.024517

Table 1.

Advisory Panel Conclusions for Prophylaxis Based on Risk of Death From Vasovagal Compromise

	Low risk	Elevated risk^*
Structural cardiac disease	1. Borderline RHD 2. Mild or moderate aortic regurgitation 3. Mild or moderate MR 4. Asymptomatic severe mitral regurgitation ^† 5. Mild or moderate mitral stenosis 6. Patients with postsurgical or interventional RHD patients who have no more than moderate residual valvular heart disease and preserved left ventricular function	1. Severe aortic insufficiency 2. Severe mitral stenosis 3. Severe aortic stenosis 4. Ventricular dysfunction (EF <50%) 5. Severe symptoms (NYHA class III or IV) ^‡
Secondary prophylaxis	Intramuscular BPG prophylaxis unless otherwise contraindicated^§	Oral antibiotics^‖ (preferably penicillin) prophylaxis unless otherwise contraindicated^§

Low risk

Elevated risk^*

Structural cardiac disease

1. Borderline RHD

2. Mild or moderate aortic regurgitation

3. Mild or moderate MR

4. Asymptomatic severe mitral regurgitation ^†

5. Mild or moderate mitral stenosis

6. Patients with postsurgical or interventional RHD patients who have no more than moderate residual valvular heart disease and preserved left ventricular function

1. Severe aortic insufficiency

2. Severe mitral stenosis

3. Severe aortic stenosis

4. Ventricular dysfunction (EF <50%)

5. Severe symptoms (NYHA class III or IV) ^‡

Secondary prophylaxis

Intramuscular BPG prophylaxis unless otherwise contraindicated^§

Oral antibiotics^‖ (preferably penicillin) prophylaxis unless otherwise contraindicated^§

BPG indicates benzathine penicillin G; EF, ejection fraction; MR, mitral regurgitation; NYHA, New York Heart Association; and RHD, rheumatic heart disease.

Risk selection should be based on the most severe component of valvular disease (ie, if mild MR but severe aortic regurgitation, then highest‐risk categorization). American College of Cardiology/American Heart Association (AHA) classification for valvular heart disease. ²²

^{^†}

We recognize that patients with isolated severe MR make up the largest and most heterogeneous group who stand to benefit from this advisory; often straddling (or moving back and forth between) low‐ and elevated‐risk categories. The decision regarding oral versus injectable penicillin for patients in this group should be adjusted on a case‐by‐case basis as needed.

^{^‡}

Includes symptoms caused by nonstructural contributing factors such as atrial fibrillation and anemia.

^{^§}

Contraindications for BPG or oral penicillin prophylaxis include prior allergic or hypersensitivity reactions, with best practice including formal allergy testing to confirm when available.

^{^‖}

Guidelines for oral prophylaxis can be drawn from AHA ⁵ or World Health Organization ²¹ recommendations or from local guidelines and best practices, where they exist.