NICE has published draft guideline on the management of heart valve disease in adults. Here is a summary of the key recommendations:
Referral
- Consider echocardiogram for adults with murmur and no other signs or symptoms if valve disease is suspected.
- Offer echocardiogram to adults with a murmur if valve disease is suspected and they have:
- signs (e.g. peripheral oedema) or symptoms (e.g. angina, dyspnoea) or an abnormal echocardiogram, or
- an ejection systolic murmur with reduced second heart sound but no other signs or symptoms.
- If valve disease is suspected:
- Offer urgent (ideally within four weeks) specialist assessment or an urgent echocardiogram to adults with systolic murmur and exertional syncope.
- Consider urgent specialist assessment for severe symptoms (angina, dyspnoea on minimal exertion or at rest).
- For guidance on the management of adults with murmur and non-exertional syncope, follow the NICE guideline on transient loss of consciousness in over 16s.
- For guidance on the management of adults with dyspnoea but no murmur, follow the NICE guideline on chronic heart failure in adults.
- Advise adults with mild valve disease to contact a health care professional if they develop symptoms.
- Offer specialist assessment for:
- moderate or severe valve disease of any type,
- bicuspid aortic valve disease of any severity, and
- mitral valve prolapse with documented ventricular arrhythmia.
- Most women with valve disease can have a pregnancy without complications.
- Seeking specialist advice on the choice of replacement valve for women of childbearing potential.
- Refer 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 and associated aortopathy, and
- a mechanical prosthetic valve.
- Refer irrespective of whether they have symptoms.
- For guidance on intrapartum care, follow the NICE guideline on intrapartum care for women with existing medical conditions or obstetric complications and their babies.
- For guidance on statins, see NICE guideline on cardiovascular disease: risk assessment and reduction, including lipid modification.
- Consider a beta-blocker for moderate to severe mitral stenosis and heart failure.
- Offer an intervention to adults with symptomatic severe heart valve disease.
- Offer clinical review every 6-12 months with echocardiogram, for asymptomatic severe valve disease if an intervention is suitable but not currently needed.
- See NICE recommendations on indications for interventions.
- Follow NICE guideline on patient experience in adult NHS services.
- Base the decision on the type of surgery (median sternotomy or minimally invasive) on patient characteristics and patient preferences.
- Consider transcatheter or re-do surgical intervention for adults with severe aortic degeneration of a biological prosthetic valve and symptoms.
- Consider referral for surgery for suitable adults with asymptomatic severe aortic stenosis if they have any of the following:
- peak aortic jet velocity (Vmax) >5 m/s on echocardiography,
- aortic valve area <0.6 cm2 on echocardiography,
- left ventricular ejection fraction (LVEF) <60% on echocardiography,
- brain natriuretic peptide/N-terminal pro b-type natriuretic peptide level more than twice the upper limit of normal, and
- symptoms unmasked on exercise testing.
- Consider referring adults with symptomatic low-flow low-gradient aortic stenosis with LVEF <50% for intervention if they have all of the following:
- mean gradient across the aortic valve <40 mmHg on echocardiography, and
- valve area <1.0 cm2, which does not increase on dobutamine stress echocardiography.
- Consider measuring aortic valve calcium score on cardiac computed tomography if the severity of symptomatic aortic stenosis is uncertain.
- Take into account the degree and distribution of calcium in the aortic valve when deciding if transcatheter aortic valve intervention (TAVI) is appropriate.
- Offer enhanced follow-up and assessment if mid-wall fibrosis is detected on cardiac magnetic resonance imaging.
- Consider referring for surgery for adults with asymptomatic severe regurgitation if there are any of the following:
- LVEF <55% on echocardiography, and
- end-systolic diameter index (ESDI) >2.4 cm/m2.
- Consider referral for asymptomatic severe mitral regurgitation if there are any of the following:
- LVEF <60%,
- ESDI >2.2 cm/m2, and
- an increase of systolic pulmonary artery pressure to >60 mmHg on exercise testing.
- Take into account the suitability of valve for repair and the presence of atrial fibrillation, or systolic pulmonary artery pressure >50 mmHg at rest, when considering referral for surgery.
- Offer surgery first-line for severe aortic stenosis, aortic regurgitation or mixed aortic valve disease.
- Offer TAVI for non-bicuspid severe aortic stenosis, if surgery is unsuitable.
- Consider transcatheter valvotomy for adults with rheumatic severe mitral stenosis, if the valve is suitable.
- Offer surgical mitral valve replacement for severe stenosis if transcatheter valvotomy is unsuitable.
- Offer surgical mitral valve repair for severe primary mitral regurgitation if surgery is suitable.
- Offer valve replacement if the valve is not suitable for repair and surgery is suitable.
- Consider transcatheter edge-to-edge repair for severe symptomatic primary mitral regurgitation if surgery is unsuitable.
- Consider surgical mitral valve repair for severe secondary mitral regurgitation and an indication for surgery, if surgery is suitable.
- Consider valve replacement for severe secondary mitral regurgitation and an indication for surgery, if the valve is not suitable for repair and surgery is suitable.
- Offer medical management in preference to transcatheter mitral edge-to-edge repair for severe secondary mitral regurgitation with heart failure if surgery is unsuitable.
- Do not offer anticoagulation after surgical biological valve replacement unless there are other indications.
- Consider aspirin, or clopidogrel if aspirin is not tolerated, after TAVI.
- For people with indications for anticoagulation or antiplatelet therapy, follow NICE guidelines on atrial fibrillation and acute coronary syndromes.
The draft guideline is open for public consultation until 5 pm on 29 April 2021. Comments can be submitted here.
References
References