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.
Key red flags
Rest/minimal-exertion breathlessness, severe angina, exertional syncope, pulmonary oedema, hypotension or new rapid AF needs urgent assessment; a murmur may be quiet when output is low.
Investigation priorities
Link symptoms to the lesion, identify AF/LVH/conduction disease and assess urgency.
First-line assessment of valve morphology and severity, LV/RV size and function, pulmonary pressure and associated aortic disease.
Management branches
Murmur or imaging suggests valve disease.
- Offer echo for murmur plus oedema, angina, breathlessness or abnormal ECG, or ejection systolic murmur plus reduced S2; consider echo for an isolated murmur when age, family history, AF or clinical features raise suspicion.
- Systolic murmur plus exertional syncope: urgent specialist assessment including echo, or urgent echo, within 2 weeks.
Key medicines
Furosemide — licensed symptomatic exampleA common oral start for oedema is 40 mg in the morning, then titrate to the lowest dose maintaining euvolaemia; smaller maintenance doses or specialist higher/divided doses may be needed.
Warfarin or another vitamin-K antagonist — guideline requirement for mechanical valvesNo safe fixed adult dose: dose to the prosthesis- and position-specific INR target set by the valve/anticoagulation team, with regular INR testing.