What is the initial management for patients with valvular heart disease?

Initial Management of Valvular Heart Disease

All patients with suspected or known valvular heart disease should undergo transthoracic echocardiography (TTE) to establish diagnosis, assess severity, and guide management decisions. 1, 2

Immediate Diagnostic Workup

Essential Initial Testing

• Perform TTE in all patients with heart murmur, symptoms suggesting valve disease, or incidental imaging findings to evaluate valve morphology, severity of stenosis/regurgitation, ventricular function, and chamber dimensions 1
• Obtain ECG to assess rhythm (atrial fibrillation is common), conduction abnormalities, and ventricular hypertrophy patterns 1, 3
• Order chest X-ray to evaluate pulmonary congestion, cardiac silhouette size, and calcification of valve structures 1, 3

When Initial Testing is Discordant

• Proceed to advanced imaging (transesophageal echocardiography, cardiac CT, or cardiac MRI) when physical examination findings conflict with TTE results or when TTE images are suboptimal 1, 2
• Consider stress testing in asymptomatic patients with severe valve disease to unmask exercise limitation or abnormal hemodynamic responses 2

Multidisciplinary Team Evaluation

Refer all patients with severe valvular heart disease being considered for intervention to a Multidisciplinary Heart Valve Team at a Primary or Comprehensive Valve Center. 2 This team must include:

• Cardiologist with valvular disease expertise 2
• Cardiovascular surgeon 2
• Structural valve interventionalist when catheter-based therapy is considered 2

Medical Management Framework

Blood Pressure Control

• Treat hypertension aggressively (target systolic BP <140 mmHg) in patients with chronic aortic regurgitation to reduce afterload and slow disease progression 1
• Control hypertension in aortic stenosis patients, though avoid abrupt BP lowering in severe stenosis 4

Heart Failure Management

• Initiate diuretics for symptomatic relief in patients with fluid retention from any valve lesion 1, 4
• Start guideline-directed medical therapy (ACE inhibitors/ARBs/sacubitril-valsartan, beta-blockers, aldosterone antagonists) in patients with severe aortic regurgitation who have symptoms and/or LV systolic dysfunction but prohibitive surgical risk 1
• Use GDMT for heart failure in secondary mitral regurgitation and tricuspid regurgitation associated with left ventricular dysfunction 1, 4

Rhythm Management

• Control ventricular rate in patients with atrial fibrillation, particularly those with mitral stenosis where maintaining adequate diastolic filling time is critical 1, 4
• Anticoagulate with vitamin K antagonist (target INR 2-3) in patients with atrial fibrillation and rheumatic mitral stenosis or mechanical prosthetic valves—NOACs are contraindicated in these populations 2
• Consider shared decision-making between vitamin K antagonist and NOAC for other valvular heart disease patients with atrial fibrillation based on CHA₂DS₂-VASc score 2

Surveillance Strategy

Asymptomatic Patients with Moderate Disease

• Schedule clinical follow-up yearly with TTE every 2 years for moderate valve disease with preserved ventricular function 1

Asymptomatic Patients with Severe Disease

• Evaluate every 6 months with annual TTE for severe valve disease with preserved ventricular function 1
• Instruct patients to report immediately any change in functional status, as symptoms may develop gradually and be unrecognized 1

Prosthetic Valves

• Obtain baseline TTE immediately post-procedure to establish reference hemodynamics 1
• Perform surveillance TTE at 5 and 10 years, then annually for bioprosthetic surgical valves 1
• Perform annual TTE for transcatheter aortic valve implantation (TAVI) 1

Critical Pitfalls to Avoid

• Do not use vasodilators (including ACE inhibitors) in asymptomatic patients with chronic primary mitral regurgitation and normal LV function—there is no evidence of benefit 1
• Do not delay intervention in symptomatic severe valve disease while attempting medical optimization, as symptoms indicate need for mechanical correction 1, 2
• Do not assume patients are asymptomatic based on their report alone—many gradually limit activity and fail to recognize symptoms; use objective exercise testing when clinical status is unclear 1, 2
• Do not use NOACs in patients with rheumatic mitral stenosis or mechanical prosthetic valves—vitamin K antagonists are mandatory 2
• Do not neglect endocarditis prophylaxis in high-risk patients (prosthetic valves, prior endocarditis, certain congenital heart disease) 1

Specific Valve Lesion Considerations

Aortic Stenosis

• No medical therapy prevents progression of calcific aortic stenosis 4, 5
• Monitor biomarkers (BNP/NT-proBNP) as significantly elevated levels may indicate need for intervention even in seemingly asymptomatic patients 2

Aortic Regurgitation

• Maintain sinus rhythm when possible, as atrial contribution to ventricular filling is important 1
• Avoid acute afterload reduction in acute severe AR; use nitroprusside cautiously with inotropic support if hypotensive 1

Mitral Regurgitation

• Distinguish primary from secondary etiology, as management differs fundamentally—secondary MR requires treatment of underlying cardiomyopathy 1, 4

Right-Sided Valve Disease

• Use diuretics for symptomatic relief in severe tricuspid regurgitation with right heart failure 1
• Treat underlying cause of secondary tricuspid regurgitation (pulmonary hypertension, left-sided disease) 1