The following are key points to remember from a 2024 report of the American College of Cardiology/American Heart Association (ACC/AHA) on performance and quality measures for adults with valvular and structural heart disease:

1. The AHA/ACC Joint Committee on Performance Measures writing committee developed new measures to evaluate the care of patients with valvular heart disease in accordance with the “2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease,” which includes a comprehensive list of 11 measures (five performance measures and six quality measures) that can be clinically used in patients with valvular heart disease.
2. The five performance measures fulfill the attributes of performance measures (e.g., high impact, targeting meaningful gaps in care, actionable, relatively low abstraction burden [in terms of cost, effort, and time], unlikely to have unintended consequences with their implementation), and are based on Class 1 clinical practice guideline recommendations and are the following:
   • In patients with a mechanical valve prosthesis, there is high-level evidence that therapy with an oral vitamin K antagonist (VKA) at an appropriate international normalized ratio goal reduces the incidence of valve thrombosis, thromboembolic events, and associated morbidity.
   • Patients with severe symptomatic aortic stenosis (AS) have a high risk of death if aortic valve intervention is not performed, as high as 50% at 1 year. Both surgical aortic valve replacement (SAVR) and transcatheter aortic valve intervention (TAVI) are effective across the spectrum of surgical risk, with significant improvements in morbidity, death, and functional status.
   • Patients with chronic severe aortic regurgitation (AR) who either have left ventricular (LV) dysfunction (ejection fraction [EF] <55%) or who develop symptoms, have a high risk of death, LV decompensation, and deterioration of functional status if aortic valve replacement is not performed.
   • Serial echocardiograms are essential to evaluate changes in LV function and structure in patients with asymptomatic chronic severe primary mitral regurgitation (MR) to guide management decisions.
   • Patients with chronic severe primary MR who develop symptoms or LVEF <60% have a high risk of death, LV decompensation, and deterioration of functional status if mitral valve intervention is not performed.
3. In addition, the five performance measures listed are appropriate for public reporting or pay-for-performance programs.
4. The quality measures on the other hand are not ready for public reporting or pay for performance but may be useful for clinicians and health care organizations for internal review and quality improvement. Quality measures may be upgraded in the future to a performance measure status after being assessed in real-world clinical practice, or can be completely retired in certain instances. For example, instances in which performance measures could be retired include very high levels of performance (“topping out”) or new evidence showing marginal clinical impact or unforeseen adverse consequences, such as risk aversion. The quality measures are:
   • Documentation of Risk and Heart Team Discussion Before SAVR or TAVI.
   • AVR for Asymptomatic AS With LV Systolic Dysfunction.
   • TAVI for Severe Symptomatic AS >80 Years of Age.
   • Post-AVR Echocardiogram.
   • Adequate Blood Pressure Control in AR Patients.
   • Treatment for Symptomatic Severe Rheumatic Mitral Stenosis.
5. All measures pertain to the outpatient setting except one quality measure that applies predominantly to the inpatient setting, which is documentation of risk and heart team discussion before SAVR or TAVI.
6. The measures are well defined and include definite exclusions (e.g., hospice, palliative care, comfort care) and relative exceptions, which may be medical- or patient-related (e.g., active bleeding, patient refusal).
7. Of the performance measures, four are related to proven therapies (one is a medical treatment and three are surgical or catheter-based interventions), and one pertains to a diagnostic modality.
8. The one performance measure pertinent to medical treatment pertains to the prescription of a VKA (e.g., warfarin) in patients with mechanical prosthetic valves, which has been proven to prevent valve thrombosis and thromboembolic events.
9. Three performance measures pertain to the implementation of an appropriate valve intervention in patients with the following: 1) severe symptomatic aortic valve stenosis; 2) chronic severe AR (symptomatic, or asymptomatic with LV systolic dysfunction); and 3) chronic severe primary MR (symptomatic, or asymptomatic with LV systolic dysfunction).
10. A notable quality measure is the objective documentation of risk while using a procedural risk score (e.g., the web-based Society of Thoracic Surgeons Risk Calculator), and documentation of a multifaceted heart valve team discussion whenever a valvular procedure or surgical intervention is being considered.

Clinical Topics: Valvular Heart Disease, Invasive Cardiovascular Angiography and Intervention, Interventions and Structural Heart Disease

Keywords: Heart Valve Diseases, Quality Improvement

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