VALVULAR
HEART DISEASE: Putting Guidelines Into Practice
Like many areas of medical care,
the management of valvular heart disease (VHD) has undergone a revolution within the
practicing lifetime of many doctors.1
Much of what we know about the natural course of VHD comes from an era before surgical
intervention, when patients presenting with symptomatic disease were unlikely to survive
more than 5 to 10 years.
It is now clear that symptoms alone are not an adequate guide. The lack of symptoms does
not predict an uncomplicated course. For example, patients with severe mitral
regurgitation can remain relatively asymptomatic while the left ventricle dilates and
irreversible functional impairment develops. Patients with severe aortic stenosis may
remain asymptomatic but are at risk of sudden death.
It is no longer appropriate to wait for change in symptoms to guide management.
New guidelines from the British Royal College of Physicians: The guidelines repeatedly recommend an echo Doppler as a pivotal tool in
decision making: to exclude VHD in those with innocent systolic murmurs; to secure a
diagnosis and judge severity in those with VHD; to establish the cause; and (using serial
measurements) to determine deterioration.
For mitral or aortic regurgitation — consider surgery when end systolic dimension is
greater than 5.5 cm.
Further prompt evaluation is needed in VHD patients who experience syncope or pulmonary
edema, develop angina, suspicion of bacterial endocarditis, or become pregnant.
"Excellent long term results with newer mechanical valve prostheses and low
perioperative mortalities...clearly tipped the balance towards earlier intervention, when
symptoms are less severe"
BMJ May 17, 1997; 312: 1428-29 Editorial from Univ. Of Otago, Dunedin, New Zealand
1. I have seen patients die of mitral stenosis because there was no surgical treatment
available at the time. RTJ
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