AHA/ACC Issue Focused Update on Valvular Heart Disease
March 15, 2017—The American Heart Association (AHA) and the American College of Cardiology (ACC) task force on clinical practice guidelines has published the 2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease. The document, authored by Rick A. Nishimura, MD, et al, is available online in the AHA journal Circulation and in Journal of the American College of Cardiology.
According to the AHA announcement of their publication, the new recommendations clarify which patients with malfunctioning heart valves may benefit from transcatheter aortic valve replacement (TAVR), clarify the need for antibiotics for some patients prior to a dental procedure, and expand the age range for choosing tissue valve replacement.
Dr. Nishimura stated in the AHA announcement, "There have been significant developments in the treatment of patients with valve disease using open heart surgery to repair rather than replace leaky valves. For example, we are now able to replace abnormal valves using a catheter-based approach, so that patients at higher risk of surgery can be treated less invasively.” Dr. Nishimura, who served as writing committee cochair for the updated, is Professor of Medicine at the Mayo Clinic in Rochester, Minnesota.
The guideline update modifies some recommendations for open-heart surgical aortic valve replacement (SAVR) and TAVR based on the results of clinical trials. For example, SAVR is recommended for people with advanced aortic stenosis who have a low or intermediate risk of surgery for either symptoms or other indications of future problems.
For patients with advanced aortic stenosis who have symptoms and are at intermediate or high risk of surgery, the writing committee found that TAVR is a reasonable alternative to SAVR.
Dr. Nishimura advised that the decision to undergo SAVR or TAVR should be a shared decision in consultation with the patient, surgeon, and cardiologist to determine the best option based on the patient’s needs and preferences. The shared decision-making approach should also be used when considering replacing a faulty valve with either a mechanical or tissue valve.
Among patients undergoing aortic or mitral valve replacement, the age range was expanded from 60 to 70 years of age to 50 to 70 years of age for the choice of either a mechanical or tissue valve. Mechanical valves, which last longer than tissue valves but may require taking blood thinners for life, were previously recommended for patients younger than 60 years of age.
Newer tissue valves, which may not require blood thinners, last longer than the earlier generation of tissue valves, without the need for replacement as often, giving patients between the ages of 50 and 60 years more options, stated Dr. Nishimura.
In addition, the update also clarifies the 2014 recommendations regarding which patients with a risk of developing infective endocarditis should receive antibiotics before certain dental procedures. The guidelines now say that giving antibiotics to prevent bacterial infection is reasonable before dental procedures for people who have had previous valve surgery or previous infection of their valve or for patients who have certain types of congenital heart disease and were born with abnormal valves. Although it is unclear how well preventive antibiotics work against infection, regular dental hygiene and a dental checkup at least every 6 months are important for anyone with valve disease or an artificial valve.
As noted in the AHA press release, the focused update is intended to help health care providers prevent symptoms, disability, and premature death in patients with valve disease. Writing committee cochair Catherine M. Otto, MD, commented, “A heart murmur often is detected on physical examination many years before symptoms appear and should prompt further evaluation with an echocardiogram. Careful periodic monitoring and medical therapy result in better long-term outcomes because patients have valve replacement at the right time; not too soon and not too late.” Dr. Otto is Professor of Medicine at the University of Washington in Seattle, Washington.