Valvular Heart Disease Clinical Practice Guidelines (ACC/AHA, 2021)

American College of Cardiology/American Heart Association

This is a quick summary of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

February 01, 2021

The American College of Cardiology (ACC) and American Heart Association (AHA) released their updated recommendations on managing valvular heart disease in December 2020.[1,2] Ten key messages are outlined below.

Top 10 Take-Home Messages

Valvular heart disease (VHD) stages (stages A-D) in patients should be classified based on symptoms, valve anatomy, severity of valve dysfunction, and response of the ventricle and pulmonary circulation.

When evaluating patients with VHD, findings from the history and physical examination (PE) should be correlated with those from noninvasive testing (ie, electrocardiography [ECG], chest x-ray, transthoracic echocardiography [TTE]). If conflict exists between results on the PE and that of initial noninvasive studies, consider obtaining further noninvasive (computed tomography [CT], cardiac magnetic resonance imaging [CMRI], stress testing) or invasive (transesophageal echocardiography [TEE], cardiac catherization) studies to decide the optimal treatment strategy.

In the setting of VHD and atrial fibrillation (AF) (except for patients with rheumatic mitral stenosis [MS] or a mechanical prosthesis), the decision to use oral anticoagulation with either a vitamin K antagonist (VKA) or a non-VKA anticoagulant to prevent thromboembolic events should be a shared decision-making process based on the CHA2DS2-VASc score (congestive heart failure [CHF], hypertension, age ≥75 years, diabetes mellitus, previous stroke/transient ischemic attack/thromboembolic event, vascular disease, age 65-74 years, sex). Oral anticoagulation with a VKA should be given to those with rheumatic MS or a mechanical prosthesis and AF.

All those with severe VHD under consideration for valve intervention should be evaluated by a multidisciplinary team, either with a referral or in consultation with a primary or comprehensive valve center.

Treatment of severe aortic stenosis (AS) with either a transcatheter or surgical valve prosthesis should be based primarily on symptoms or reduced ventricular systolic function. Consider earlier intervention if indicated by the results of exercise testing, biomarkers, rapid progression, or the presence of very severe stenosis.

Expanded indications for transcatheter aortic valve implantation (TAVI) are a result of findings from multiple randomized trials of TAVI versus surgical aortic valve replacement (SAVR). The selection of intervention type for patients with severe AS should be a shared decision-making process that considers the lifetime risks and benefits associated with the valve type (mechanical vs bioprosthetic) and approach type (transcatheter vs surgical).

Indications for intervention for valvular regurgitation are symptomatic relief and prevention of the irreversible long-term consequences of left ventricular volume overload. Lowered thresholds for intervention than they were previously are owing to more durable treatment options and lower procedural risks.

A mitral transcatheter edge-to-edge repair benefits patients with severely symptomatic primary mitral regurgitation (MR) who are at high or prohibitive surgical risk, as well as benefits a select subset of patients with secondary MR who remain severely symptomatic despite guideline-directed management and heart failure therapy.

Patients who present with severe symptomatic isolated tricuspid regurgitation, commonly associated with device leads and AF, may benefit from surgical intervention to reduce symptoms and recurrent hospitalizations if performed before the onset of severe right ventricular dysfunction or hepatic and renal end-organ damage.

Bioprosthetic valve dysfunction may occur because of either degeneration of the valve leaflets or valve thrombosis. Catheter-based treatment for prosthetic valve dysfunction is reasonable in selected patients for bioprosthetic leaflet degeneration or paravalvular leak in the absence of active infection.

For more information, please go to Aortic Stenosis, Aortic Regurgitation, Mitral Stenosis, Mitral Regurgitation, and Tricuspid Regurgitation.

For more Clinical Practice Guidelines, please go to Guidelines.

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