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Heart Valve Disease Guideline 2020

CardioSmart News

To incorporate new evidence about treatments for heart valve disease, the American College of Cardiology and American Heart Association have released the 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease. The new guideline, written by a team of experts, replaces the 2014 guideline and 2017 focused update.  

Heart valve disease includes a range of conditions that occur when any of the heart’s four valves don’t work properly. Most heart valve problems involve the aortic and mitral valves. Common problems include when a valve can’t open wide enough to let blood through (stenosis) or can’t close tightly enough to prevent blood from flowing back into the heart (regurgitation). Some problems, such as aortic stenosis, usually develop later in life as people age. At the same time, people can be born with valve problems.

With heart valve disease, the heart must work harder and may not be able to pump enough blood out to the rest of the body. As a result, people can experience shortness of breath, unusual fatigue, dizziness, or swelling in ankles, feet, or belly. If heart valve disease isn’t treated, it can get worse over time and lead to heart failure or even death.  

The management of heart valve disease continues to evolve thanks to ongoing research. Here are key points from the latest recommendations.

Aortic Stenosis

If you have severe aortic stenosis, you may need to decide whether to fix your valve. The new guideline expands the use of transcatheter aortic valve replacement, or TAVR, to more patients. This less invasive procedure to replace an aortic valve is also referred to as transcatheter aortic valve implantation, or TAVI.

Not too long ago, surgery usually was considered the best option for valve replacement. But based on growing evidence and recent clinical trials that included patients (mean age in the mid-70s) who had low-to-intermediate surgical risk, TAVR may now also be considered for some people who have a low surgical risk.

Besides picking the method for valve replacement (TAVR or surgery), another important choice involves what type of valve to use (mechanical or bioprosthetic). The main concerns about replacement valves focus on how long they will last, and the medications needed to prevent dangerous blood clots.

These choices involve many factors, and sometimes the path forward is unclear. The guideline encourages engaging patients in these treatment considerations via shared decision-making. Such discussions allow patients the chance to share their goals and concerns. Also, in-depth conversations between patients and their care team will help ensure a full understanding of valve types and replacement options, including the risks and benefits of each one, or the possibility that another surgery or procedure might be needed. These steps will help ensure that each patient receives the treatment that is right for them.

Mitral Regurgitation

Another update involves the use of valve replacement in patients with mitral regurgitation (MR). Until recently, the main treatment options for MR involved medication or open-heart surgery. A new, less invasive procedure is now considered reasonable for some patients.

Mitral regurgitation falls into two categories: primary MR (degenerative) caused by a problem with the mitral valve itself; and secondary MR (functional) caused by a problem with the left bottom chamber, or ventricle, of the heart.

The less-invasive procedure—a percutaneous edge-to-edge mitral repair—can be considered reasonable in patients with primary MR and for some patients with secondary MR who have severe symptoms and are being treated with medication for heart failure.

Blood Thinners

After more research, recommendations now cover the use of non-vitamin K oral anticoagulants (blood thinners also known as NOACs) in patients with heart valve disease and atrial fibrillation. NOACs have been shown to be an effective option to traditional blood thinners with a vitamin K antagonist (warfarin).

The guideline recommends engaging in shared decision-making based on a CHA2DS2-VASC score, which is a tool used to predict the chances someone with atrial fibrillation will have a stroke. Note: This recommendation does not apply to patients with rheumatic mitral stenosis or who have a mechanical heart valve.  

Team Approach

A multidisciplinary team approach helps provide heart valve patients with the best possible care. Patients with heart valve disease should have a team of health care providers who work together to help manage their condition. It also is reasonable for certain patients to seek care at a specialized center, such as patients who have severe heart valve disease but no symptoms or patients who might benefit from valve repair vs. replacement.  

Partners in Care

As the treatment options for patients continue to change, the partnership between patients and their clinicians becomes even more important. Shared decision-making can help patients weigh treatment options when the path forward is not clear. Today, less invasive treatments are becoming more common. Future research may uncover ways to prevent heart valve disease or slow its progression.

More information

Learn more about heart valve disease:

2020 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease,” Journal of the American College of Cardiology, Dec. 17, 2020. 

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