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Valvular Heart Disease Guidelines Provide New Disease Classification

Document expands patients suitable for procedures

New practice guidelines for the management of patients with valvular heart disease (VHD) provide updated definitions of disease severity — categorizing four progressive stages from “at risk” to “symptomatic severe” — and lower the threshold for intervention in specific patient populations.

Released March 3 by the American College of Cardiology and the American Heart Association, the 2014 document further incorporates a more complex evaluation of interventional risk than did previous guidelines and incorporates indications for newer catheter-based therapies.

The guidelines were drafted by a committee that included cardiologists, interventionalists, surgeons, and anesthesiologists, and are the first to be released on VHD since a focused update in 2008.

Among the document’s most significant additions is the new classification of VHD stages. Created to help clinicians determine the optimal timing of intervention, the stages consider the degree of valve narrowing or leakage, the presence of symptoms, the response of the left and/or right ventricle to the valve lesion, and any change in heart rhythm.

The guidelines also provide a proposed risk assessment that should be applied to all patients considered for intervention. Acknowledging that current scoring systems are useful but limited, the document’s original assessment combines procedure-specific impediments, major organ-system compromise, comorbidities, patient frailty, and the Society of Thoracic Surgeons predicted risk of mortality model. The risk scores — along with the specific risks and benefits — should be discussed with patients in a shared decision-making process to determine the best therapy for the individual.

The guidelines further address, for the first time, the use of transcatheter aortic valve replacement (TAVR). The introduction of TAVR and other new catheter-based therapies have made VHD management increasingly complex, as they have expanded patient options but increased the difficulty of discerning the risk–benefit ratio. The guidelines therefore provide separate recommendations on both the timing and choice of these new interventions.

Moreover, the new therapies now mandate a multidisciplinary approach to the diagnosis and management of VHD, said writing committee co-chair Catherine Otto, MD. In response, the guidelines discuss both the Heart Valve Team and Heart Valve Centers of Excellence.

Treatment advances have also impacted the interventional threshold. “Due to more knowledge regarding the natural history of untreated patients with severe VHD and better outcomes from surgery, we’ve lowered the threshold for operation to include more patients with asymptomatic severe valve disease,” said Rick Nishimura, MD, writing committee co-chair. “Now, select patients with severe asymptomatic aortic stenosis and severe asymptomatic mitral regurgitation can be considered for intervention, depending on certain other factors, such as operative mortality and, in the case of mitral regurgitation, the ability to achieve a durable valve repair.”

Finally, the guidelines include formatting enhancements to facilitate their use at the point of care. Decision-pathway diagrams have been incorporated, as have numerous summary tables. According to Otto, the new format will facilitate both greater clinical use and a more timely and efficient updating process.

Source: AHA; March 3, 2014.

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