New ACC/AHA VHD Guideline Spotlights Less-Invasive Treatments

The ACC and the American Heart Association (AHA) have released an updated Guideline for the Management of Patients With Valvular Heart Disease (VHD) that includes expanded treatment options, recommends fewer invasive interventions, when possible, and stresses the importance of patient involvement in treatment considerations.

The guideline, published in the Journal of the American College of Cardiology, replaces the 2014 guideline and a focused update from 2017 and includes an extensive review of available data through March 1, 2020. Of note, the guideline highlights the expansion of indications for transcatheter aortic valve implantation (TAVI) as a result of multiple randomized trials of TAVI vs. surgical aortic valve replacement. According to the guideline, "the choice of type of intervention for a patient with severe aortic stenosis should be a shared decision-making process that considers the lifetime risks and benefits associated with type of valve (mechanical vs. bioprosthetic) and type of approach (transcatheter vs. surgical)."

In addition, the evidence for non-vitamin K oral anticoagulants (NOACs) has improved since the last guideline was published, and the new guideline includes a class 1 level A recommendation that states: "For patients with AFib and native valve heart disease (except rheumatic mitral stenosis) or who received a bioprosthetic valve >3 months ago, a NOAC is an effective alternative to VKA anticoagulation and should be administered on the basis of the patient's CHA2DS2-VASc score."

Other recommendations address the optimal timing of intervention for severe aortic stenosis depending on the severity of the valve condition, as well as the safety and long-term effectiveness of treatment options. The guideline authors note that the recommended timing of interventions will shift to earlier in the disease course for some patients as ongoing clinical research data evolves. Additionally, the guideline recommends that patients with severe VHD and who are being considered for valve repair or replacement should be evaluated by a specialized team working with a primary or comprehensive valve center.

Shared decision-making and the use of less-invasive treatment options are other important aspects of the new guideline. "Clinical studies have demonstrated the safety and effectiveness of new, less-invasive approaches for treatment of heart valve dysfunction," said Catherine Otto, MD, FACC, co-chair of the guideline writing committee. "Integration of this expanded evidence base, in conjunction with expert clinical experience, will furnish both providers and patients with the guidance needed to ensure optimal outcomes for patients with heart valve conditions."

Looking ahead, the guideline committee recommends more disease-specific studies and patient-centered trials that focus on each stage of the disease process. "While this guideline focuses on patients with end-stage heart valve disease, future research will also lead to treatments to prevent heart valve disease or earlier interventions to slow its progression," explains Otto.

"There is a knowledge explosion in medicine today, which can overwhelm the clinician," said Rick A. Nishimura, MD, MACC, co-chair of the writing committee. "This is particularly true in the area of VHD, in which multiple investigational trials are being rapidly performed and released, so that it becomes extremely difficult for an individual clinician to keep up with optimal treatments for each specific patient. The Valvular Heart Disease Guideline brings together experts in the field who review all the data and arrive at a consensus opinion for best treatment, outlined in the Class Recommendations."

The College has developed a clinician-focused VHD Guidelines Made Simple Tool, as well as a patient-focused CardioSmart Patient Summary. These tools and more are available on the ACC VHD Guideline Hub. Additionally, don't miss two VHD Guideline-focused case reports in JACC: Case Reports from McCauley, et al., and Shetty, et al. More resources are also available on the Guideline Hub.

Clinical Topics: Anticoagulation Management, Cardiac Surgery, Congenital Heart Disease and Pediatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and CHD and Pediatrics, Cardiac Surgery and VHD, Congenital Heart Disease, CHD and Pediatrics and Imaging, CHD and Pediatrics and Interventions, Interventions and Imaging, Interventions and Structural Heart Disease, Interventions and Vascular Medicine, Angiography, Echocardiography/Ultrasound, Magnetic Resonance Imaging, Nuclear Imaging, Mitral Regurgitation

Keywords: Anticoagulants, Fibrinolytic Agents, Platelet Aggregation Inhibitors, Aortic Valve Insufficiency, Aortic Valve Stenosis, Aortic Valve, Aortic Diseases, Perioperative Period, Cardiac Catheterization, Cardiac Imaging Techniques, Magnetic Resonance Imaging, Cardiovascular Surgical Procedures, Diagnostic Techniques, Cardiovascular, Drug Therapy, Echocardiography, Endocarditis, Exercise Test, Diagnostic Imaging, Angiography, Hemodynamics, Mitral Valve Stenosis, Mitral Valve Insufficiency, Heart Murmurs, Mitral Valve, Pregnancy, Heart Valve Prosthesis, Decision Making, Heart Valve Diseases, Heart Defects, Congenital, Patient Care Team, Thromboembolism, Thrombosis, Transcatheter Aortic Valve Replacement, Heart Valve Prosthesis Implantation, Catheters, Echocardiography, Transesophageal, Tricuspid Valve

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