Notable Changes in New Valvular Disease Guidelines
ACCEL | Moderate-to-severe valvular heart disease (VHD) is present in 2.5% of the US population and increases in prevalence with age. For example, it affects between 4% and 9% of those 65 to 75 years of age and 12% to 13% of those > 75 years of age.
Many of these patients require surgical or interventional procedures. However, even with intervention, overall survival is lower than expected, and the risk of adverse outcomes due to VHD is high, both because of limited options for restoring normal valve function and failure to intervene at the optimal time point in the disease course.
In 2014, new ACC/AHA guidelines were released on the management of patients with VHD, the first focused update on the condition and its treatment since 2008. The new document is in a different format from prior VHD guidelines to facilitate access to concise, relevant bites of information at the point of care when clinical knowledge is needed the most.1
For example, each Class of Recommendation (COR) is followed by a brief paragraph of supporting text and references. Also, the new document includes restructured definitions of disease severity and provides a more complex evaluation of interventional risk and indications for newer catheter-based therapies.
It’s the latter that may be the most notable change in the updated guidelines. Instead of focusing on end-stage disease, the new guidelines address the broad spectrum of patients, ranging from the person at risk to end-stage disease. Towards that end, the restructured definitions cover the stages of progression in VHD— “at risk,” “progressive” (formerly considered mild-to-moderate disease), “asymptomatic severe,” and “symptomatic severe”—which 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.
Focusing on the stages of disease may make it easier for clinicians to halt or delay disease progression from one stage to the next, before patients become symptomatic. Catherine M. Otto, MD, co-chair of the valvular guidelines writing committee, said too often clinicians wait too long, sometimes even delaying until patients pass from early to late symptoms before intervening. “We want to be able to intervene right at the time of that first symptom or even a little before,” she said. To do that requires considering the stages of disease and intervening before patients get to the most advanced stage.
The guidelines state that the management of patients with VHD requires a multidisciplinary team approach and heart valve centers of excellence to allow for multidisciplinary care of complex patients with valvular heart disease. Specifically, the guideline recommends patients with severe VHD be evaluated by a multidisciplinary heart valve team when intervention is considered (COR I). Consultation with or referral to a heart valve center of excellence is reasonable when discussing treatment options for: 1) asymptomatic patients with severe VHD, 2) patients who may benefit from valve repair versus valve replacement, or 3) patients with multiple comorbidities for whom valve intervention is considered (COR IIa).
In order to improve risk assessment, the updated guideline provides a new method to be applied to all patients considered for intervention. Combining procedure-specific impediments (e.g., vascular access issues), major organ system compromise (that will not improve post-procedure), 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 recommended to be discussed with the patient in a shared decision-making process to determine optimal 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 provided new options but have also made VHD management increasingly complex.
Follow-up of patients with VHD is important to assess symptom status, provide patient education, and monitor disease severity, typically with periodic echocardiography.
The guidelines conclude by noting that we urgently need research on almost every aspect of VHD to ensure that patients who already have VHD receive optimal therapy and to prevent VHD in those at risk. Approaches to improving outcomes in patients with VHD include:
- national and international registries and randomized clinical trials,
- continuous evaluation of outcomes data at each Heart Valve Center of Excellence, and a focus on patient-centric care with involvement of the patient in the decision-making process.
Nishimura RA, Otto CM, Bonow RO, et al. J Am Coll Cardiol. 2014;63:e57-e185.
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