Results have been published in which both exercise and dobu- tamine were used with Doppler echocardiography, although exercise is preferred in general as the more Most experience is with tread- mill exercise, with images and Doppler obtained immediately after stress, but bicycle exercise allows data acquisition at various stages of exercise. Bicycle exercise testing during cardiac catheterization can also be performed for direct measurements of pul- monary artery wedge pressure and pulmonary pres- sures at rest and with exercise. Simple functional capacity helps to quantify the patient s symptoms. Changes in valve gradient should be measured, as well as the estimated pulmonary artery systolic pressure. If the patient cannot exercise, increasing the heart rate with maneuvers such as leg lifts or sit-ups may be useful. 6.2.2. Medical Therapy Recommendations for Medical Therapy in Patients With Rheumatic MS Referenced studies that support the recommendations are summarized in Online Data Supplement 20. COR LOE Recommendations In patients with rheumatic MS and 1) AF, 2) a prior embolic event, or 3) an LA thrombus, anticoagulation with a VKA is indicated.1 7 In patients with rheumatic MS and AF with a rapid ventricular response, heart rate control can be beneficial.8 In patients with rheumatic MS in normal sinus rhythm with symptomatic resting or exertional sinus tachycardia, heart rate control can be beneficial to manage symptoms.9 15 Synopsis In patients with rheumatic MS and AF, anticoagulation decreases the incidence of thromboembolic events. An- ticoagulation can also decrease the incidence of throm- boembolic events in patients with rheumatic MS if there has been a prior embolic event or if an LA throm- bus was visualized. 