Rapid detection and treatment of streptococcal pharyngitis constitute primary prevention of rheumatic fever. For patients with previous episodes of rheumatic fever or in those with evidence of rheumatic heart dis- ease, long-term antistreptococcal prophylaxis is indicat- ed for secondary prevention.1 Recommendation-Specific Supportive Text 1. Recurrent rheumatic fever is associated with a worsening of rheumatic heart disease. However, infection with group A streptococcus does not have to be symptomatic to trigger a recurrence, and rheumatic fever can recur even when the symptomatic infection is treated. Prevention of recurrent rheumatic fever requires long-term anti- microbial prophylaxis rather than recognition and treatment of acute episodes of group A strepto- coccus pharyngitis. The recommended treatment regimens and duration of secondary prophylaxis are shown in Tables 6 and 7. 2.4.2. IE Prophylaxis Recommendations for IE Prophylaxis Referenced studies that support the recommendations are summarized in Online Data Supplement 1. COR LOE Recommendations Antibiotic prophylaxis is reasonable before dental procedures that involve manipulation of gingival tissue, manipulation of the periapical region of teeth, or perforation of the oral mucosa in patients with VHD who have any of : a. Prosthetic cardiac valves, including transcatheter-implanted prostheses and homografts. b. Prosthetic material used for cardiac valve repair, such as annuloplasty rings, chords, or clips. c. Previous IE. d. Unrepaired cyanotic congenital heart disease or repaired congenital heart disease, with residual shunts or valvular regurgitation at the site of or adjacent to the site of a prosthetic patch or prosthetic device. e. Cardiac transplant with valve regurgitation attributable to a structurally abnormal valve. Benefit B-NR In patients with VHD who are at high risk of IE, antibiotic prophylaxis is not recommended for nondental procedures (eg, TEE, esophagogastroduodenoscopy, colonoscopy, or cystoscopy) in the absence of active Table 6. 