https://www.zora.uzh.ch/id/eprint/150846/1/ehx391.pdf

2017 ESC/EACTS Guidelines for the management of valvular heart disease

Guidelines and Expert Consensus Documents aim to present management recommendations based on all of the relevant evidence on a particular subject in order to help physicians select the best possible management strategies for the individual patient suffering from a specific condition, taking into account the impact on outcome and also the risk–benefit ratio of a particular diagnostic or therapeutic procedure. Numerous studies have demonstrated that patient outcomes improve when guideline recommendations, based on the rigorous assessment of evidence-based research, are applied in clinical practice.

A great number of Guidelines and Expert Consensus Documents have been issued in recent years by the European Society of Cardiology (ESC) and also by other organizations or related societies. The profusion of documents can put at stake the authority and credibility of guidelines, particularly if discrepancies appear between different documents on the same issue, as this can lead to confusion in the minds of physicians. In order to avoid these pitfalls, the ESC and other organizations have issued recommendations for formulating and issuing Guidelines and Expert Consensus Documents. The ESC recommendations for guidelines production can be found on the ESC website.1 It is beyond the scope of this preamble to recall all but the basic rules.

In brief, the ESC appoints experts in the field to carry out a comprehensive review of the literature, with a view to making a critical evaluation of the use of diagnostic and therapeutic procedures and assessing the risk–benefit ratio of the therapies recommended for management and/or prevention of a given condition. Estimates of expected health outcomes are included, where data exist. The strength of evidence for or against particular procedures or treatments is weighed according to predefined scales for grading recommendations and levels of evidence, as outlined in what follows.

The Task Force members of the writing panels, …

Guidelines on the management of valvular heart disease The Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology

ACE
: angiotensin-converting enzyme
AF
: atrial fibrillation
aPTT
: activated partial thromboplastin time
AR
: aortic regurgitation
ARB
: angiotensin receptor blockers
AS
: aortic stenosis
AVR
: aortic valve replacement
BNP
: B-type natriuretic peptide
BSA
: body surface area
CABG
: coronary artery bypass grafting
CAD
: coronary artery disease
CMR
: cardiac magnetic resonance
CPG
: Committee for Practice Guidelines
CRT
: cardiac resynchronization therapy
CT
: computed tomography
EACTS
: European Association for Cardio-Thoracic Surgery
ECG
: electrocardiogram
EF
: ejection fraction
EROA
: effective regurgitant orifice area
ESC
: European Society of Cardiology
EVEREST
: (Endovascular Valve Edge-to-Edge REpair STudy)
HF
: heart failure
INR
: international normalized ratio
LA
: left atrial
LMWH
: low molecular weight heparin
LV
: left ventricular
LVEF
: left ventricular ejection fraction
LVEDD
: left ventricular end-diastolic diameter
LVESD
: left ventricular end-systolic diameter
MR
: mitral regurgitation
MS
: mitral stenosis
MSCT
: multi-slice computed tomography
NYHA
: New York Heart Association
PISA
: proximal isovelocity surface area
PMC
: percutaneous mitral commissurotomy
PVL
: paravalvular leak
RV
: right ventricular
rtPA
: recombinant tissue plasminogen activator
SVD
: structural valve deterioration
STS
: Society of Thoracic Surgeons
TAPSE
: tricuspid annular plane systolic excursion
TAVI
: transcatheter aortic valve implantation
TOE
: transoesophageal echocardiography
TR
: tricuspid regurgitation
TS
: tricuspid stenosis
TTE
: transthoracic echocardiography
UFH
: unfractionated heparin
VHD
: valvular heart disease
3DE
: three-dimensional echocardiography

Guidelines summarize and evaluate all evidence available, at the time of the writing process, on a particular issue with the aim of assisting physicians in selecting the best management strategies for an individual patient with a given condition, taking into account the impact on outcome, as well …

Guidelines on the management of valvular heart disease (version 2012)

https://journal.chestnet.org/article/S0012-3692(08)60117-8/pdf

Pharmacology and management of the vitamin K antagonists: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition).

/pdf/guidelines-on-the-management-of-valvular-heart-disease-34x2ig8vw4.pdf

Guidelines on the management of valvular heart disease (version 2012)The Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)

Aims In mechanical heart valve recipients, low-dose international normalized ratio (INR) self-management of oral anticoagulants can reduce the risk of developing thrombo-embolic events and improve long-term survival compared with INR control by a general practitioner. Here, we present data on the safety of low-dose INR self-management.

Methods and results In a prospective, randomized multi-centre trial, 1346 patients with a target INR range of 2.5–4.5 and 1327 patients with a target INR range of 1.8–2.8 for aortic valve recipients and an INR range of 2.5–3.5 for mitral or double valve recipients were followed up for 24 months. The incidence of thrombo-embolic events that required hospital admission was 0.37 and 0.19% per patient year in the conventional and low-dose groups, respectively ( P = 0.79). No thrombo-embolic events occurred in the subgroups of patients with mitral or double valve replacement. The incidence of bleeding events that required hospital admission was 1.52 and 1.42%, respectively ( P = 0.69). In the majority of patients with bleeding events, INR values were < 3.0. Mortality rate did not differ between the study groups.

Conclusion Data demonstrate that low-dose INR self-management does not increase the risk of thrombo-embolic events compared with conventional dose INR self-management. Even in patients with low INR target range, the risk of bleeding events is still higher than the risk of thrombo-embolism.

Low-dose oral anticoagulation in patients with mechanical heart valve prostheses: final report from the early self-management anticoagulation trial II.

International normalized ratio self-management lowers the risk of thromboembolic events after prosthetic heart valve replacement.

Aim To study in patients performing international normalized ratio (INR) self-control the efficacy and safety of an INR target range of 1.6–2.1 for aortic valve replacement (AVR) and 2.0–2.5 for mitral valve replacement (MVR) or double valve replacement (DVR).

Methods and results In total, 1304 patients undergoing AVR, 189 undergoing MVR and 78 undergoing DVR were randomly assigned to low-dose INR self-control (LOW group) (INR target range, AVR: 1.8–2.8; MVR/DVR: 2.5–3.5) or very low-dose INR self-control once a week (VLO group) and twice a week (VLT group) (INR target range, AVR: 1.6–2.1; MVR/DVR: 2.0–2.5), with electronically guided transfer of INR values. We compared grade III complications (major bleeding and thrombotic events; primary end-points) and overall mortality (secondary end-point) across the three treatment groups.

Findings Two-year freedom from bleedings in the LOW, VLO, and VLT groups was 96.3, 98.6, and 99.1%, respectively ( P = 0.008). The corresponding values for thrombotic events were 99.0, 99.8, and 98.9%, respectively ( P = 0.258). The risk-adjusted composite of grade III complications was in the per-protocol population (reference: LOW-dose group) as follows: hazard ratio = 0.307 (95% CI: 0.102–0.926; P = 0.036) for the VLO group and = 0.241 (95% CI: 0.070–0.836; P = 0.025) for the VLT group. The corresponding values of 2-year mortality were = 1.685 (95% CI: 0.473–5.996; P = 0.421) for the VLO group and = 4.70 (95% CI: 1.62–13.60; P = 0.004) for the VLT group.

Conclusion Telemedicine-guided very low-dose INR self-control is comparable with low-dose INR in thrombotic risk, and is superior in bleeding risk. Weekly testing is sufficient. Given the small number of MVR and DVR patients, results are only valid for AVR patients.

Otto Wagner

Papers

Low-dose oral anticoagulation in patients with mechanical heart valve prostheses: final report from the early self-management anticoagulation trial II.

International normalized ratio self-management lowers the risk of thromboembolic events after prosthetic heart valve replacement.

Telemedicine-guided, very low-dose international normalized ratio self-control in patients with mechanical heart valve implants.

Low-dose international normalized ratio self-management: a promising tool to achieve low complication rates after mechanical heart valve replacement.