Red Flags
- Acute severe aortic regurgitation (acute AR with hypotension and pulmonary oedema) — emergency surgery; vasodilators and inotropes as bridge[1]
- Severe symptomatic aortic stenosis with syncope, angina, or heart failure — without intervention 2-year mortality > 50%[1]
- Severe primary mitral regurgitation with new heart failure, atrial fibrillation, or pulmonary hypertension — surgery indicated[1]
- Suspected infective endocarditis with new murmur and fever — blood cultures plus echocardiography urgent[1]
First-line treatment
Interventions
- Heart team evaluation[1]Multidisciplinary team — clinical, imaging, interventional, surgical, heart failure, palliative care — for any severe valve disease being considered for intervention
- Surgical aortic valve replacement (SAVR)[1]Severe symptomatic aortic stenosis in low surgical risk; bicuspid valve; need for concomitant procedure (CABG, aortic root surgery, multivalve)
- Transcatheter aortic valve replacement (TAVR)[1]Severe symptomatic aortic stenosis in intermediate, high, or prohibitive surgical risk; selected low-risk patients age ≥ 65 after heart-team evaluation
- Mitral valve repair (preferred over replacement)[1]Primary degenerative severe mitral regurgitation; transcatheter edge-to-edge repair (TEER) for symptomatic primary MR with prohibitive surgical risk and for selected secondary MR despite optimal HF therapy
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Furosemide[1] | Loop diuretic | 20–80 mg PO daily; titrate to symptom control | — | Symptom relief in volume overload; medical therapy in valvular disease does not prevent progression |
| Warfarin[1] | Vitamin K antagonist | Mechanical mitral valve INR 2.5–3.5; mechanical aortic valve INR 2.0–3.0; bridge with heparin during interruption | — | Mechanical heart valves require warfarin — DOACs contraindicated. Bioprosthetic valves: 3 months warfarin then antiplatelet |
| Apixaban[1] | DOAC (factor Xa inhibitor) | 5 mg PO BD (reduce per package insert) | — | AF with bioprosthetic valve >3 months post-implant — DOACs preferred. Contraindicated with mechanical valves and moderate/severe rheumatic mitral stenosis |
Furosemide[1]
Loop diuretic
- Adult
- 20–80 mg PO daily; titrate to symptom control
- Paediatric
- —
Symptom relief in volume overload; medical therapy in valvular disease does not prevent progression
Warfarin[1]
Vitamin K antagonist
- Adult
- Mechanical mitral valve INR 2.5–3.5; mechanical aortic valve INR 2.0–3.0; bridge with heparin during interruption
- Paediatric
- —
Mechanical heart valves require warfarin — DOACs contraindicated. Bioprosthetic valves: 3 months warfarin then antiplatelet
Apixaban[1]
DOAC (factor Xa inhibitor)
- Adult
- 5 mg PO BD (reduce per package insert)
- Paediatric
- —
AF with bioprosthetic valve >3 months post-implant — DOACs preferred. Contraindicated with mechanical valves and moderate/severe rheumatic mitral stenosis
Safety-net
- Attend every echocardiogram appointment — silent worsening of valve disease drives the timing of surgery[1]
- New shortness of breath, chest pain, dizziness, or fainting — same-day medical review; symptoms in severe valve disease warrant urgent intervention[1]
- If you have a mechanical valve: never miss a warfarin dose, attend INR monitoring, and avoid DOACs and aspirin alone[1]
Referral criteria
- Acute severe aortic or mitral regurgitation with haemodynamic instabilityEmergency department; urgent cardiothoracic surgery[1]
- Severe symptomatic aortic stenosis or severe mitral regurgitation with HF, AF, or pulmonary hypertensionHeart team for SAVR/TAVR or mitral valve repair evaluation[1]
- Asymptomatic severe valve disease with progressive LV dysfunction (LVEF <60% in MR or <50% in AS) or progressive LV dilationHeart team for early intervention discussion[1]
- Prosthetic valve dysfunction (regurgitation, thrombosis, pannus, dehiscence) or suspected endocarditisCardiology and cardiothoracic surgery same-day[1]
Clinical summary
Diagnosis, surveillance, and intervention for adults with valvular heart disease — aortic stenosis/regurgitation, mitral regurgitation/stenosis, tricuspid disease.