ACC/AHA Issue 2014 Valvular Heart Disease Guideline

March 3, 2014—The American College of Cardiology (ACC) and the American Heart Association (AHA) announced the publication of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease. The guideline is the first to be released on valvular heart disease (VHD) since a focused update in 2008. For the first time, the guideline addresses the use of transcatheter aortic valve replacement (TAVR).

The document provides practice guidance for managing patients with VHD with updated definitions of disease severity, categorizing four progressive stages from “at risk” to “symptomatic severe” and lowering the threshold for intervention in select patient populations. Additionally, the 2014 document incorporates a more complex evaluation of interventional risk than the previous guideline, as well as indications for newer catheter-based therapies.

The guideline is currently available on the ACC and AHA websites, www.cardiosource.org and www.americanheart.org, respectively. It will be published in a future issue of the ACC’s Journal of the American College of Cardiology and the AHA’s Circulation. An executive summary is also available online in Journal of the American College of Cardiology and  Circulation.

The writing committee Co-Chairs are Catherine Otto, MD, and Rick Nishimura, MD. Dr. Otto is Professor of Medicine at the University of Washington Medical School and Director of the UW Medical Center Heart Valve Clinic. Dr. Nishimura is a consultant in the Division of Cardiovascular Diseases at the Mayo Clinic.

The societies noted that the work of the writing committee was supported exclusively by the ACC and AHA and without commercial support. All writing committee members disclosed all current health care–related relationships. The committee’s co-chairs had no relevant relationships with industry, and the committee was formed to include a majority of members with no relevant relationships with industry.

The guideline was drafted by a committee that included cardiologists, interventionists, surgeons, and anesthesiologists. The 2014 guideline was developed in collaboration with the American Association for Thoracic Surgery, American Society for Echocardiography, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons (STS).

According to the ACC/AHA announcement, the document’s new classification of VHD stages was created to help clinicians when evaluating the optimal timing of intervention, 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 guideline also provides a proposed risk assessment that should be applied to all patients who are being considered for intervention. Acknowledging that current scoring systems are useful but limited, the guideline provides an original assessment that combines procedure-specific impediments, major organ system compromise, comorbidities, patient frailty, and the STS-predicted risk of mortality model. The 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, noted the ACC/AHA.

The guideline notes that 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 guideline thus provides separate recommendations on both the timing and choice of these new interventions.

In the ACC/AHA press release, Dr. Otto advised that the new therapies now mandate a multidisciplinary approach to the diagnosis and management of VHD. The guideline discusses the utility of Heart Valve Teams and Heart Valve Centers of Excellence. 

Regarding treatment advances that have affected the interventional threshold, Dr. Nishimura commented, “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. 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 guideline includes formatting enhancements to facilitate their use at the point of care. Decision pathway diagrams have been incorporated, as have numerous summary tables. The new format will facilitate both greater clinical use and a more timely and efficient updating process, noted Dr. Otto.

Dr. Otto further commented, “This VHD guideline was developed in a modular format that will allow the update or addition of individual recommendations based on the publication of new evidence. This novel approach to evidence-based guideline development will revolutionize the clinical impact of guideline recommendations, ensuring they are always current and allowing seamless integration with electronic medical record systems.”

In related news, an overview of transcatheter therapies for mitral regurgitation was jointly issued by the ACC, American Association for Thoracic Surgery, Society for Cardiovascular Angiography and Interventions, and STS. The overview document was made available online on November 25, 2013, and published in the March 2014 print edition of the Journal of the American College of Cardiology (2014;63:840–852).