New Guideline for the Management of Patients with Valvular Heart Disease Released
New practice guidelines for the management of patients with valvular heart disease (VHD) were released March 3 by the ACC and the American Heart Association. The first focused update on the condition and its treatment since 2008, the new guideline includes restructured definitions of disease severity, and provides a more complex evaluation of interventional risk and indications for newer catheter-based therapies.
Perhaps the most notable update is the restructured definitions. Divided into four classifications — "at risk," "progressive," "asymptomatic severe," and "symptomatic severe" — these categories were created to help clinicians determine the optimal timing of intervention. The stages take into consideration the degree of valve narrowing or leakage, the presence of symptoms, the response of the left and/or right ventricle to the valve lesion, and any change in heart rhythm.
Acknowledging the limitations of its predecessor's approach to risk assessment, the updated guideline also provides a new proposed method to be applied to all patients considered for intervention. Combining procedure-specific impediments, major organ system compromise, comorbidities, patient frailty, and the Society of Thoracic Surgeons' predicted risk of mortality model, the calculated risk scores — along with more specific risks and benefits — are to be discussed with the patient in a shared decision-making process to determine the best therapy.
The VHD guideline also addresses, for the first time, the complex use and management of transcatheter aortic valve replacement (TAVR). The introduction of TAVR and other new catheter-based therapies have made VHD management increasingly complex. In an effort to help discern the risk-benefit ratio of the expanded options the treatment provides, the guideline includes recommendations on both the timing and choice of this particular intervention.
Other highlights include a recommendation for the use of Heart Valve Teams and Heart Valve Centers of Excellence to allow for multidisciplinary care of complex patients with valvular heart disease. Writing Committee Co-Chair Rick Nishimura, MD, MACC, also notes that the guideline provides a lower threshold for operation to include more patients with asymptomatic severe valve disease. "Now, select patients with severe asymptomatic aortic stenosis and severe asymptomatic mitral regurgitation can be considered for intervention, depending on certain other factors, such as operative mortality and in the case of mitral regurgitation, the ability to achieve a durable valve repair," he said.
Finally, the guideline includes formatting enhancements to facilitate their use at the point of care. Decision pathway diagrams have been incorporated, as have numerous summary tables. "This VHD guideline was developed in a modular format that will allow the update or addition of individual recommendations based on the publication of new evidence," said Writing Committee Co-Chair Catherine Otto, MD, FACC. "This novel approach to evidence-based guideline development will revolutionize the clinical impact of guideline recommendations, ensuring they are always current and allowing seamless integration with electronic medical record systems."
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