Heart Valve Disease Presenting in Adults: Investigation and Management

Overview

This Guidelines summary covers the investigation and management of heart valve disease in adults, including referral, pharmacological management, monitoring, and advice.

This summary only contains key recommendations for primary care. For the complete set of recommendations, refer to the full guideline.

Referral for Echocardiography and Specialist Assessment

Referral for Echocardiography

• Consider an echocardiogram for adults with a murmur and no other signs or symptoms if valve disease is suspected based on:
  • the nature of the murmur
  • family history
  • age (especially if over 75), or
  • medical history (for example, a history of atrial fibrillation).
• Offer an echocardiogram to adults with a murmur if valve disease is suspected (based on the nature of the murmur, family history, age or medical history) and they have:
  • signs (such as peripheral oedema) or symptoms (such as angina or breathlessness) or an abnormal ECG, or
  • an ejection systolic murmur with a reduced second heart sound but no other signs or symptoms.

Referral for Urgent Specialist Assessment or Urgent Echocardiography

• If valve disease is suspected (based on the nature of the murmur, family history, age or medical history):
  • Offer urgent (within 2 weeks) specialist assessment that includes echocardiogram or if not available an urgent echocardiogram alone to adults with a systolic murmur and exertional syncope.
  • Consider urgent (within 2 weeks) specialist assessment that includes echocardiogram for adults with a murmur and severe symptoms (angina or breathlessness on minimal exertion or at rest) thought to be related to valvular heart disease.
• For guidance on referral and assessment for adults with murmur and non-exertional syncope, follow the recommendations in the NICE guideline on transient loss of consciousness (‘blackouts’) in over 16s.
• For guidance on referral and assessment for adults with breathlessness but no murmur, follow the recommendations in the NICE guideline on chronic heart failure in adults.

Referral to a Specialist After Echocardiography

• Be aware that mild valve disease is common and rarely progresses to become clinically significant
• Offer referral to a specialist to:
  • adults with moderate or severe valve disease of any type
  • adults with bicuspid aortic valve disease of any severity (including mild valve disease).

Information, Referral and Specialist Assessment for Pregnant Women and Women Considering Pregnancy

• Be aware that most women with valve disease can have a pregnancy without complications.
• Offer advice on the implications of treatment choices on any future pregnancy to women who need heart valve intervention.
• Offer advice on family planning to women with severe valve disease, particularly aortic and mitral stenosis.
• Refer pregnant women or women who are considering a pregnancy to a cardiologist with expertise in the care of pregnant women, if they have any of the following:
  • moderate or severe valve disease
  • bicuspid aortic valve disease of any severity (including mild disease) and associated aortopathy
  • a prosthetic valve.Refer whether they have symptoms or not.
• Consider seeking specialist advice on the choice of replacement valve if heart valve replacement surgery is being considered for women of childbearing potential.
• For guidance on intrapartum care, follow the recommendations on heart disease in the NICE guideline on intrapartum care for women with existing medical conditions or obstetric complications and their babies.

Pharmacological Management

Management of Heart Failure in People With Valve Disease

• Consider a beta-blocker for adults with moderate to severe mitral stenosis and heart failure.
• When adults with heart valve conditions and heart failure also have left ventricular dysfunction, refer to the NICE guideline on chronic heart failure in adults.

Indications for Interventions

• Offer an intervention to adults with symptomatic severe heart valve disease.

Aortic Stenosis

• Consider referring adults with asymptomatic severe aortic stenosis for intervention, if suitable, if they have any of the following:
  • Vmax (peak aortic jet velocity) more than 5 m/s on echocardiography
  • aortic valve area less than 0.6 cm² on echocardiography
  • left ventricular ejection fraction (LVEF) less than 55%
  • B-type natriuretic peptide (BNP) or N-terminal proBNP (NT-proBNP) level more than twice the upper limit of normal
  • symptoms unmasked on exercise testing.
• Consider referring adults with symptomatic low-gradient aortic stenosis with LVEF less than 50% for intervention if during dobutamine stress echocardiography the aortic stenosis is shown to be severe by:
  • a mean gradient across the aortic valve that increases to more than 40 mmHg and
  • an aortic valve area that remains less than 1 cm².
• Consider measuring aortic valve calcium score on cardiac CT if the severity of symptomatic aortic stenosis is uncertain.
• Offer enhanced follow up (for example, more frequent reviews) and further assessment (for example, stress echocardiography) to monitor the need for intervention if mid-wall fibrosis is detected on cardiac MRI in adults with severe aortic stenosis.

Aortic Regurgitation

• Consider referring adults with asymptomatic severe aortic regurgitation for intervention, if suitable, if they have either of the following:
  • LVEF less than 55% or
  • end systolic diameter (ESD) of more than 50 mm or end systolic diameter index (ESDI) more than 24 mm/m² on echocardiography.

Mitral Regurgitation

• Consider referring adults with asymptomatic severe primary mitral regurgitation for intervention, if suitable, if they have any of the following:
  • LVEF less than 60%
  • ESD more than 45 mm or ESDI more than 22 mm/m² on echocardiography or
  • an increase of systolic pulmonary artery pressure to more than 60 mmHg on exercise testing.When making decisions about referral for surgery, take into account the suitability of the valve for repair and the presence of atrial fibrillation or systolic pulmonary artery pressure of more than 50 mmHg on echocardiography at rest.

Monitoring When There is No Current Need for Intervention

• Offer clinical review every 6 to 12 months, with an echocardiogram, to adults with asymptomatic severe valve disease if an intervention is suitable but not currently needed. Base the frequency of the review on echocardiography findings and shared decision making with the patient.
• Consider echocardiographic assessment every 3 to 5 years for adults with mild aortic or mitral stenosis.

Interventions

See the recommendations on indications for interventions.

Decisions About Interventions

• Discuss the possible benefits and risks of interventions with adults who have an indication for valve intervention. Include in the discussion:
  • the benefits to quality of life (both in the short and long term)
  • prosthetic valve durability
  • the risks associated with the procedures
  • the type of access for surgery (median sternotomy, minimally invasive surgery or, for people at high surgical risk, transcatheter)
  • the possible need for other cardiac procedures in the future.Follow the recommendations in the NICE guidelines on shared decision making and patient experience in adult NHS services and base decisions on the type of intervention on patient characteristics and preferences.
• When surgery is agreed, base the decision on the type of surgery (median sternotomy or minimally invasive surgery) on patient characteristics and preferences. If minimally invasive surgery is the agreed option and is not available locally, refer the person to another centre.

For intervention recommendations for aortic valve disease, mitral stenosis, mitral regurgitation, and repeat interventions, refer to the full guideline.

Anticoagulation and Antiplatelet Therapy

• Do not offer anticoagulation after surgical biological valve replacement unless there are other indications for anticoagulation.
• Consider aspirin, or clopidogrel if aspirin is not tolerated, after TAVI.
• If people have other indications for anticoagulation or antiplatelet therapy, follow the recommendations in the NICE guidelines on atrial fibrillation and acute coronary syndromes.

Monitoring After an Intervention

• Base decisions on the frequency and type of monitoring for adults who have had an intervention (valve repair or replacement) for valve disease on:
  • durability of the prosthetic valve or durability of the repair
  • the presence of another condition, including other heart disease
  • residual valve abnormality or consequences of the procedure, for example, paravalvular leak
  • concerns about abnormal function of the prosthetic valve
  • the patient’s wishes.Advise people and their family members or carers (as appropriate) to seek advice if the heart condition deteriorates.

Information and Advice

• Follow the NICE guideline on shared decision making and the recommendations in the NICE guideline on patient experience in adult NHS services on:
  • involvement of family members and carers
  • communication
  • information
  • tailoring healthcare services.
• Consider providing a point of contact for accessing specialist advice between appointments.
• Be aware of the psychological impact on the person receiving a diagnosis of valve disease, whether or not they have symptoms. Consider the person’s needs for additional information and support.
• Provide information and advice to adults with valve disease about:
  • the expected progression and prognosis of their condition, including the likely length of an asymptomatic stage
  • any need for intervention, including the type of intervention
  • pregnancy, if appropriate
  • the possible effects of other conditions on long-term outcomes
  • rehabilitation and long-term outcomes
  • palliative care, if appropriate, including how to access this.
• Provide information and support to young adults about transition from paediatric to adult services, in line with the NICE guideline on transition from children’s to adults’ services for young people using health or social care services.