What is the management of congestive heart failure (CHF) with valvular heart disease?

Management of CHF with Valvular Heart Disease

In patients with CHF and valvular heart disease, surgical valve intervention is the definitive treatment when severe valvular disease is present, while medical management with guideline-directed medical therapy (GDMT) should be optimized before and after surgery, with specific cautions regarding vasodilators in severe aortic stenosis. 1

Initial Assessment and Diagnosis

Coronary angiography is mandatory in patients with heart failure and evidence of significant valvular disease to establish diagnosis and plan treatment strategy (Class I, Level of Evidence C). 1 This evaluation should occur before any valve intervention to identify concomitant coronary artery disease that may require revascularization. 1

Key diagnostic steps include:

• Comprehensive echocardiographic assessment with attention to valve severity, left ventricular ejection fraction, and chamber dimensions 1
• Evaluation for viable myocardium in patients with CAD using dobutamine echocardiography, nuclear imaging (SPECT/PET), or cardiac MRI 1
• Assessment of cardiovascular and non-cardiovascular comorbidities that impact surgical risk 1

Medical Management Strategy

For HFrEF with Valvular Disease

Continue and optimize GDMT during hospitalization unless contraindicated (Class I, Level of Evidence B-NR). 1 This includes:

• ACE inhibitors/ARBs/ARNIs: Maintain therapy even with mild renal function decline or asymptomatic blood pressure reduction 1
• Beta-blockers: Continue at maximally tolerated doses 1
• Mineralocorticoid receptor antagonists: Continue with careful monitoring of potassium and renal function 1
• Diuretics: Titrate to achieve euvolemia and relieve congestion 1

Critical caveat for aortic stenosis: Vasodilators (ACE inhibitors, ARBs, nitrates) may cause substantial hypotension in patients with severe aortic stenosis and should be used only with great caution. 1 Medical treatment should be optimized but not delay the decision regarding valve surgery. 1

For HFpEF with Valvular Disease

• SGLT2 inhibitors (dapagliflozin or empagliflozin) as first-line disease-modifying therapy 2, 3
• Loop diuretics at the lowest effective dose to manage congestion 2, 3
• Avoid calcium channel blockers (diltiazem, verapamil) as they increase risk of heart failure worsening 3

Surgical Indications by Valve Lesion

Aortic Stenosis

Surgery is recommended (Class I, Level of Evidence C) in:

• Eligible patients with HF symptoms and severe AS 1
• Asymptomatic patients with severe AS and impaired LVEF (<50%) 1

Surgery may be considered (Class IIb, Level of Evidence C) in patients with severely reduced valve area and LV dysfunction. 1

Aortic Regurgitation

Surgery is recommended (Class I, Level of Evidence B) in:

• All eligible patients with severe AR who have symptoms of HF 1
• Patients with LVEF >30% (valve repair if possible) (Class I, Level of Evidence C) 1

Surgery may be considered for patients with severe AR and LVEF <30%; medical therapy should be first choice, with surgery only if patients remain refractory to pharmacological treatment. 1

Mitral Regurgitation

Organic (primary) MR: Development of HF symptoms with severe organic MR due to structural valve abnormality is a strong indication for surgery. 1

Functional (secondary) MR: Surgery may be considered in symptomatic patients with poor LV function, but decisions require careful consideration of patient motivation, biological age, and risk profile. 1

Perioperative and Postoperative Management

Optimal medical management of both HF and comorbid conditions prior to surgery is imperative. Emergency surgery should be avoided if possible. 1

Decisions should be based on:

• Thorough clinical and echocardiographic assessment 1
• Attention to cardiovascular and non-cardiovascular comorbidities 1
• Patient's motivation, biological age, and risk profile 1

After valve intervention, patients should receive:

• Standard GDMT for LV systolic dysfunction if present 1
• Secondary prevention measures to reduce future cardiovascular events 1
• Continued optimization of heart-healthy lifestyle factors 1

Common Pitfalls to Avoid

Do not discontinue GDMT prematurely during hospitalization for mild renal function decline or asymptomatic hypotension. 1 Diuresis and other GDMT should not routinely be discontinued in these situations. 1

Do not delay valve surgery while attempting to optimize medical therapy in patients with severe symptomatic valvular disease, particularly severe aortic stenosis or aortic regurgitation. 1

Avoid NSAIDs in patients with heart failure, as they cause fluid retention and attenuate diuretic effects. 4

Do not use aggressive vasodilator therapy in severe aortic stenosis without extreme caution due to risk of profound hypotension. 1

Monitoring During Medical Management

For patients on mineralocorticoid receptor antagonists, check blood biochemistry at 1 and 4 weeks after starting/increasing dose, then at 8 and 12 weeks, 6,9, and 12 months, and every 4 months thereafter. 4

If serum potassium exceeds 5.5 mmol/L, reduce MRA dose by half; if potassium exceeds 6.0 mmol/L or creatinine exceeds 310 μmol/L (3.5 mg/dL), stop MRA immediately. 4