For the first time since 2014, the American College of Cardiology (ACC) and the American Heart Association (AHA) have updated their recommendations for the management of patients with valvular heart disease.
The 2017 publication—which includes only updates and additions to the 2014 guidelines—focuses on anticoagulation in atrial fibrillation, interventions in aortic stenosis, infective endocarditis, mitral regurgitation, and various other issues related to prosthetic valves. The updated guidelines have been published jointly in Circulation (July 14, 2017; doi:0000000000000503) and in the Journal of the American College of Cardiology (July 14, 2017; doi:10.1016/j.jacc.2017.03.011).
In a new section dedicated to anticoagulation, guideline panelists recommend using direct oral anticoagulation in patients with atrial fibrillation and valvular disease, with the exception of those patients with a prosthetic mechanical valve or rheumatic mitral stenosis. According to Catherine M Otto, MD, co-chair of the writing committee for the update, professor of medicine, University of Washington, in an interview (July 14, 2017), “This is a huge change for patients because many more patients will now be able to take these newer, more convenient, safer and more effective agents.”
Another prominent update in the guidelines relates to aortic stenosis. Indications for which patients should undergo surgical aortic valve replacement remain the same, but the need to individualize valve selection is being reinforced, particularly in patients with intermediate-risk. “We continue to recommend that surgery is appropriate as well, so the heart valve team is integral in trying to determine which is more appropriate for individual patients: surgical or transcatheter valve replacement,” said Dr Otto.
When determining whether aortic valve replacement or transcatheter valve replacement is appropriate in intermediate-risk patients, factors such as vascular access, comorbid conditions that may affect the risk of either intervention, expected functional status and survival after surgical aortic valve replacement, and patient preferences should be considered, according to the guidelines.
Additionally, the guidelines recommend considering bioprosthetic valves in patients aged at least 50 years, whereas the 2014 guidelines recommended the same treatment, but for patients aged at least 60 years.
“This update was motivated largely by changes in the management of aortic stenosis related to several important, new studies on transcatheter aortic valve replacement showing better outcomes in lower-risk patients as well as in higher-risk patients,” commented Dr Otto. “We also looked across the spectrum of valvular heart disease and found other updates were needed as well.”—Zachary Bessette