NICE Draft Guidance on Management of Heart Valve Disease

Dawn O'Shea

Disclosures

March 19, 2021

The National Institute for Health and Care Excellence (NICE) has published a draft guideline on the management of heart valve disease in adults. Here is a summary of the key recommendations:

Referral

  1. Consider echocardiogram for adults with murmur and no other signs or symptoms if valve disease is suspected.

  2. 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.

  1. 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).

  1. 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.

  2. For guidance on the management of adults with dyspnoea but no murmur, follow the NICE guideline on chronic heart failure in adults.

Referral following echocardiography

  1. Advise adults with mild valve disease to contact a health care professional if they develop symptoms.

  2. 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.

Pregnant women and women considering pregnancy

  1. Most women with valve disease can have a pregnancy without complications.

  2. Seeking specialist advice on the choice of replacement valve for women of childbearing potential.

  3. 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.

  1. Refer irrespective of whether they have symptoms.

  2. For guidance on intrapartum care, follow the NICE guideline on intrapartum care for women with existing medical conditions or obstetric complications and their babies.

Management

  1. For guidance on statins, see NICE guideline on cardiovascular disease: risk assessment and reduction, including lipid modification.

  2. Consider a beta-blocker for moderate to severe mitral stenosis and heart failure.

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

  4. Offer clinical review every 6-12 months with echocardiogram, for asymptomatic severe valve disease if an intervention is suitable but not currently needed.

  5. See NICE recommendations on indications for interventions.

  6. Follow NICE guideline on patient experience in adult NHS services.

  7. Base the decision on the type of surgery (median sternotomy or minimally invasive) on patient characteristics and patient preferences.

  8. Consider transcatheter or re-do surgical intervention for adults with severe aortic degeneration of a biological prosthetic valve and symptoms.

Aortic stenosis

  1. 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.

  1. 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.

  1. Consider measuring aortic valve calcium score on cardiac computed tomography if the severity of symptomatic aortic stenosis is uncertain.

  2. Take into account the degree and distribution of calcium in the aortic valve when deciding if transcatheter aortic valve intervention (TAVI) is appropriate.

  3. Offer enhanced follow-up and assessment if mid-wall fibrosis is detected on cardiac magnetic resonance imaging.

Aortic regurgitation

  1. 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.

Mitral regurgitation

  1. 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.

  1. 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.

Aortic valve disease

  1. Offer surgery first-line for severe aortic stenosis, aortic regurgitation or mixed aortic valve disease.

  2. Offer TAVI for non-bicuspid severe aortic stenosis, if surgery is unsuitable.

Mitral stenosis

  1. Consider transcatheter valvotomy for adults with rheumatic severe mitral stenosis, if the valve is suitable.

  2. Offer surgical mitral valve replacement for severe stenosis if transcatheter valvotomy is unsuitable.

Primary mitral regurgitation

  1. Offer surgical mitral valve repair for severe primary mitral regurgitation if surgery is suitable.

  2. Offer valve replacement if the valve is not suitable for repair and surgery is suitable.

  3. Consider transcatheter edge-to-edge repair for severe symptomatic primary mitral regurgitation if surgery is unsuitable.

Secondary mitral regurgitation

  1. Consider surgical mitral valve repair for severe secondary mitral regurgitation and an indication for surgery, if surgery is suitable.

  2. 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.

  3. Offer medical management in preference to transcatheter mitral edge-to-edge repair for severe secondary mitral regurgitation with heart failure if surgery is unsuitable.

Anticoagulation and antiplatelet therapy

  1. Do not offer anticoagulation after surgical biological valve replacement unless there are other indications.

  2. Consider aspirin, or clopidogrel if aspirin is not tolerated, after TAVI.

  3. 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.

This clinical summary originally appeared on Univadis, part of the Medscape Professional Network.

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