2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

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2021 ESC/EACTS Guidelines for the management of valvular heart disease.

Aim: This executive summary of the valvular heart disease guideline provides recommendations for clinicians to diagnose and manage valvular heart disease as well as supporting documentation to enco...

2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.

2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease

2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary

Objective Cardiac auscultation is a key clinical skill, particularly for the diagnosis of valvular heart disease (VHD). However, its utility has declined due to the widespread availability of echocardiography and diminishing emphasis on the importance of clinical examination. We aim to determine the contemporary accuracy of auscultation for diagnosing VHD in primary care. Methods Cardiac auscultation was undertaken by one of two experienced general practitioners (primary care/family doctors) in a subset of 251 asymptomatic participants aged >65 years undergoing echocardiography within a large community-based screening study of subjects with no known VHD. Investigators were blinded to the echocardiographic findings. Newly detected VHD was classified as mild (mild regurgitation of any valve or aortic sclerosis) or significant (at least moderate regurgitation or mild stenosis of any valve). Results Newly identified VHD was common, with mild disease in 170/251 participants (68%) and significant disease in 36/251 (14%). The sensitivity of auscultation was low for the diagnosis of mild VHD (32%) but slightly higher for significant VHD (44%), with specificities of 67% and 69%, respectively. Likelihood ratios were not statistically significant for the diagnosis of either mild or significant VHD in the overall cohort, but showed possible value for auscultation in non-overweight subjects (body mass index 2 ). Conclusion Cardiac auscultation has limited accuracy for the detection of VHD in asymptomatic patients and is a poor diagnostic screening tool in primary care, particularly for overweight subjects. Ensuring easy access to echocardiography in patients with symptoms suggesting VHD is likely to represent a better diagnostic strategy.

https://heart.bmj.com/content/heartjnl/104/22/1832.full.pdf

Cardiac auscultation poorly predicts the presence of valvular heart disease in asymptomatic primary care patients.

Objective The study aims were (1) to identify the community prevalence of moderate or greater mitral or tricuspid regurgitation (MR/TR), (2) to compare subjects identified by population screening with those with known valvular heart disease (VHD), (3) to understand the mechanisms of MR/TR and (4) to assess the rate of valve intervention and long-term outcome. Methods Adults aged ≥65 years registered at seven family medicine practices in Oxfordshire, UK were screened for inclusion (n=9504). Subjects with known VHD were identified from hospital records and those without VHD invited to undergo transthoracic echocardiography (TTE) within the Oxford Valvular Heart Disease Population Study (OxVALVE). The study population ultimately comprised 4755 subjects. The severity and aetiology of MR and TR were assessed by integrated comprehensive TTE assessment. Results The prevalence of moderate or greater MR and TR was 3.5% (95% CI 3.1 to 3.8) and 2.6% (95% CI 2.3 to 2.9), respectively. Primary MR was the most common aetiology (124/203, 61.1%). Almost half of cases were newly diagnosed by screening: MR 98/203 (48.3%), TR 69/155 (44.5%). Subjects diagnosed by screening were less symptomatic, more likely to have primary MR and had a lower incidence of aortic valve disease. Surgical intervention was undertaken in six subjects (2.4%) over a median follow-up of 64 months. Five-year survival was 79.8% in subjects with isolated MR, 84.8% in those with isolated TR, and 59.4% in those with combined MR and TR (p=0.0005). Conclusions Moderate or greater MR/TR is common, age-dependent and is underdiagnosed. Current rates of valve intervention are extremely low.

https://heart.bmj.com/content/heartjnl/early/2021/03/03/heartjnl-2020-318482.full.pdf

Community prevalence, mechanisms and outcome of mitral or tricuspid regurgitation.

P5437Cardiac auscultation in diagnosing valvular heart disease: a comparison between general practitioners and cardiologists

Introduction Cardiac auscultation is an important clinical skill used by physicians in assessing and diagnosing valvular heart disease (VHD). The widespread use of echocardiography in the last three decades has coincided with a perceived decline in the utility of auscultation, particularly by general physicians. The ability of generalists to identify VHD in an unselected population has not been well characterised, so we aimed to determine the accuracy of auscultation in primary care for diagnosing VHD. Methods 251 participants aged 65 and over who were participating in the OxValve population cohort study were included. They were recruited from two participating GP surgeries and had no previous diagnosis of VHD. The participants underwent cardiac auscultation during the OxValve study visit by two experienced General Practitioners (GPs), neither of whom had a specialist interest in cardiology. A 5-point Likert scale was used to rate the ability to hear heart sounds (1=not at all; 5=perfectly) in addition to the presence or absence of a murmur, type of murmur and the ability to make a diagnosis based upon the auscultation findings. This was compared to transthoracic echocardiography performed at the same visit, but GPs were blind to the echocardiogram result, which was performed after auscultation. VHD was categorised as mild (either mild regurgitation [excluding trace/physiological] or aortic sclerosis) or significant (moderate/severe regurgitation or at least mild stenosis). Standard measures of diagnostic accuracy were calculated. Results 82 murmurs were heard by the GPs (80 systolic; 2 diastolic). Echocardiography identified mild VHD in 174 (69%) of the 251 participants, with more significant VHD present in 37 (15%). The ability to hear a murmur on auscultation was not related to age, BMI or heart rate (table 1). Auscultation had a sensitivity of 32% and specificity of 67% for diagnosing mild VHD, which improved slightly for significant VHD to a sensitivity of 43%, and specificity of 69% (table 2). The area under the curve on receiver operating characteristics (ROC) analysis was 0.50 for mild VHD and 0.56 for significant VHD (Figure-1) suggesting limited discriminatory ability. Conclusion GP auscultation has only moderate accuracy for diagnosing valvular heart disease in an unselected population, and the presence of an isolated murmur would not be a reliable indicator of valve disease. This study did not include patients with cardiovascular symptoms however, in whom the presence of a murmur may be more significant, and for whom echocardiography might be more appropriate.

https://heart.bmj.com/content/heartjnl/103/Suppl_5/A101.full.pdf

Anthony Prothero

Papers

Cardiac auscultation poorly predicts the presence of valvular heart disease in asymptomatic primary care patients.

Community prevalence, mechanisms and outcome of mitral or tricuspid regurgitation.

P5437Cardiac auscultation in diagnosing valvular heart disease: a comparison between general practitioners and cardiologists

136 Gp auscultation for diagnosing valvular heart disease