New practice guidelines have been released by the American College of Cardiology and the American Heart Association which aim to clarify the management of patients with valvular heart disease. The guidelines provide updated definitions of disease severity. Patients will now be categorized in four progressive stages from “at risk” to “symptomatic severe”. Certain patient populations will find the threshold for intervention lowered.
The new 2014 document, a first update for six years, was drafted by a committee including cardiologists, interventionalists, surgeons, and anesthesiologists. It also incorporates a more complex evaluation of interventional risk than the previous guidelines. For the first time the guidance incorporates indications for newer catheter-based therapies, so now encompasses transcatheter valve replacement.
Valvular Heart Disease stage
Among the document’s most significant additions is the new classification of Valvular Heart Disease stages. The guidelines aim to help clinicians determine several key components. Firstly the optimal timing of intervention, consideration of 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.
Risk Assessment for Intervention
The guideline also provides 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 several factors. These include procedure-specific impediments, major organ system compromise, comorbidities, patient frailty, and the Society of Thoracic Surgeons predicted risk of mortality model. The guidelines say risk scores, along with the specific risks and benefits, should be discussed with the patient in a shared decision-making process to determine the best therapy for the individual.
For the first time the guidance covers the use of transcatheter aortic valve replacement (TAVR). The introduction of TAVR and other new catheter-based therapies have made Valvular Heart Disease management increasingly complex, as they have expanded patient options but increased the difficulty of discerning the risk–benefit ratio. The guideline thus provides separate recommendations on both the timing and choice of these new interventions.