Valvular heart disease

Synopsis

Recognise clinically important valve disease, request echocardiography at the right urgency, know surveillance and intervention thresholds, and avoid substituting symptomatic medicines for definitive valve treatment.

• Offer echocardiography when a murmur is accompanied by oedema, angina, breathlessness or an abnormal ECG, or when an ejection systolic murmur has a reduced second heart sound.
• A systolic murmur plus exertional syncope requires urgent specialist assessment including echocardiography, or urgent echo, within 2 weeks.
• After echo, offer specialist referral for any moderate or severe valve disease and for bicuspid aortic valve of any severity.
• Offer intervention for symptomatic severe valve disease when suitable; tablets do not reverse a severe mechanical lesion.
• In asymptomatic severe aortic stenosis, intervention assessment is triggered by Vmax above 5 m/s, valve area below 0.6 cm², LVEF below 55%, natriuretic peptide above twice the upper reference limit, or symptoms on exercise testing.
• Asymptomatic severe aortic regurgitation needs intervention assessment when LVEF is below 55%, LV end-systolic diameter above 50 mm or indexed diameter above 24 mm/m².
• Asymptomatic severe primary mitral regurgitation needs intervention assessment when LVEF is below 60%, LV end-systolic diameter above 45 mm/indexed above 22 mm/m², or exercise pulmonary artery systolic pressure exceeds 60 mmHg.
• TAVI versus SAVR must be a valve-MDT decision using age, anatomy, bicuspid status, surgical risk, durability, access and preference. NHS England's September 2023 interim commissioning position permits TAVI as an alternative for selected lower-risk patients in England; it is not a UK-wide NICE default and must be rechecked before use.