BONOW
ET AL., ACC/AHA TASK FORCE REPORT
JACC Vol. 32, No. 5, November 1998:1486-1588
ACC/AHA
Guidelines for the Management of Patients With Valvular
Heart Disease
Preamble
It
is important that the medical profession play a significant
role in critically evaluating the use of diagnostic
procedures and therapies in the management or prevention
of disease states. Rigorous and expert analysis of the
available data documenting relative benefits and risks
of those procedures and therapies can produce helpful
guidelines that improve the effectiveness of care, optimize
patient outcomes, and favorably impact the overall cost
of care by focusing resources on the most effective
strategies.
The
American College of Cardiology (ACC) and the American
Heart Association (AHA) have jointly engaged in the
production of such guidelines in the area of cardiovascular
disease since 1980. This effort is directed by the ACC/AHA
Task Force on Practice Guidelines. Its charge is to
develop and revise practice guidelines for important
cardiovascular diseases and procedures. Experts in the
subject under consideration are selected from both organizations
to examine subject-specific data and write guidelines.
The process includes additional representatives from
other medical specialty groups when appropriate. Writing
groups are specifically charged to perform a formal
literature review, weigh the strength of evidence for
or against a particular treatment or procedure, and
include estimates of expected health outcomes where
data exist. Patient-specific modifiers, comorbidities,
and issues of patient preference that might influence
the choice of particular tests or therapies are considered
as well as frequency of follow-up and cost-effectiveness.
These
practice guidelines are intended to assist physicians
in clinical decision making by describing a range of
generally acceptable approaches for the diagnosis, management,
or prevention of specific diseases or conditions. These
guidelines attempt to define practices that meet the
needs of most patients in most circumstances. The ultimate
judgment regarding care of a particular patient must
be made by the physician and patient in light of all
the circumstances presented by that patient.
The
Committee on Management of Patients With Valvular Heart
Disease was chaired by Robert O. Bonow, MD, FACC, and
included the following members: Blase Carabello, MD,
FACC; Antonio C. de Leon, Jr., MD, FACC; L. Henry Edmunds,
Jr., MD, FACC; Bradley J. Fedderly, MD, FAAFP; Michael
D. Freed, MD, FACC; William H. Gaasch, MD, FACC; Charles
R. McKay, MD, FACC; Rick A. Nishimura, MD, FACC; Patrick
T. O'Gara, MD, FACC; Robert A. O'Rourke, MD, FACC; and
Shahbudin H. Rahimtoola, MD, FACC. In August 1998, the
full text of the guidelines was approved for publication
in the November issue of the Journal of the American
College of Cardiology and the executive summary
for publication in the November 3 issue of Circulation.
Reprints of both the full text and the executive summary
are available from both organizations.
I.
Introduction
The
American College of Cardiology and the American Heart
Association (ACC/AHA) have long been involved in the
joint development of practice guidelines designed to
assist physicians in the management of selected cardiovascular
disorders or the selection of certain cardiovascular
procedures. The determination of the disorders or procedures
for which to develop guidelines is based on several
factors, including importance to physicians and whether
there are sufficient data from which to derive accepted
guidelines. One important category of cardiac disorders
that affect a large number of patients who require diagnostic
procedures and decisions regarding long-term management
is valvular heart disease.
During
the past 2 decades, major advances have occurred in
diagnostic techniques, the understanding of natural
history, and interventional cardiological and surgical
procedures for patients with valvular heart disease.
These advances have resulted in enhanced diagnosis,
more scientific selection of patients for surgery or
catheter-based intervention versus medical management,
and increased survival of patients with these disorders.
The information base from which to make clinical management
decisions has greatly expanded in recent years, yet
in many situations management issues remain controversial
or uncertain. Unlike many other forms of cardiovascular
disease, there is a scarcity of large-scale multicenter
trials addressing the diagnosis and treatment of patients
with valvular disease from which to derive definitive
conclusions, and the information available in the literature
represents primarily the experiences reported by single
institutions in relatively small numbers of patients.
The
Committee on Management of Patients With Valvular Heart
Disease was given the task of reviewing and compiling
this information base and making recommendations for
diagnostic testing, treatment, and physical activity.
For topics in which there is an absence of multiple
randomized controlled trials, the preferred basis for
medical decision making in clinical practice (evidence-based
medicine), the committee's recommendations were based
on data derived from single randomized trials or nonrandomized
studies or were based on a consensus opinion of experts.
Where no or few data exist, this is identified in the
text.
The
committee membership consisted of cardiovascular disease
specialists as well as representatives of the cardiac
surgery and family practice fields; both the academic
and private practice sectors were represented. This
document was reviewed by 3 outside reviewers nominated
by the ACC and 3 outside reviewers nominated by the
AHA, as well as numerous content reviewers and individuals
nominated by the American Academy of Family Physicians
and the Society of Thoracic Surgeons.
The
guidelines follow the format established in previous
ACC/AHA guidelines for classifying indications for diagnostic
and therapeutic procedures:
Class
I: Conditions for which there is evidence and/or general
agreement that a given procedure or treatment is useful
and effective.
Class
II: Conditions for which there is conflicting evidence
and/or a divergence of opinion about the usefulness/efficacy
of a procedure or treatment.
IIa. Weight
of evidence/opinion is in favor of usefulness/efficacy.
IIb. Usefulness/efficacy
is less well established by evidence/opinion.
Class
III: Conditions for which there is evidence and/or
general agreement that the procedure/treatment is not
useful and in some cases may be harmful.
The
reference list is not exhaustive or all-inclusive, as
this would be beyond the scope of this publication,
but includes those papers that the committee believes
represent the most comprehensive or convincing data
and are necessary to support its conclusions.
The
guidelines attempt to deal with general issues of treatment
of patients with heart valve disorders, such as evaluation
of patients with heart murmurs, prevention and treatment
of endocarditis, management of valve disease in pregnancy,
and treatment of patients with concomitant coronary
artery disease (CAD) as well as more specialized issues
that pertain to specific valve lesions. The guidelines
focus primarily on valvular heart disease in the adult,
with a separate section dealing with specific recommendations
for valve disorders in adolescents and young adults.
The diagnosis and management of infants and young children
with congenital valvular abnormalities are significantly
different from those of the adolescent or adult and
are beyond the scope of these guidelines.
This
task force report overlaps with several previously published
ACC/AHA guidelines about cardiac imaging and diagnostic
testing, including the Guidelines for Clinical Use of
Cardiac Radionuclide Imaging (1), the Guidelines for
Clinical Application of Echocardiography (2), the Guidelines
for Exercise Testing (3), and the Guidelines for Coronary
Angiography (4). Although these guidelines are not intended
to include detailed information covered in previous
guidelines on the use of imaging and diagnostic testing,
an essential component of this report is the discussion
of indications for these tests in the evaluation and
treatment of patients with valvular heart disease.
The
committee emphasizes the fact that many factors ultimately
determine the most appropriate treatment of individual
patients with valvular heart disease within a given
community. These include the availability of diagnostic
equipment and expert diagnosticians, the expertise of
interventional cardiologists and surgeons, and notably
the wishes of well-informed patients. Therefore, deviation
from these guidelines may be appropriate in some circumstances.
These guidelines are written with the assumption that
a diagnostic test can be performed and interpreted with
skill levels consistent with previously reported ACC
training and competency statements and ACC/AHA guidelines,
that interventional cardiological and surgical procedures
can be performed by highly trained practitioners within
acceptable safety standards, and that the resources
necessary to perform these diagnostic procedures and
provide this care are readily available. This is not
true in all geographic areas, which further underscores
the committee's position that its recommendations are
guidelines and not rigid requirements.
©
1998 American College of Cardiology and American Heart
Association, Inc. Published by Elsevier
Science Inc.
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