Cardiology · AHA

Valvular heart disease

AHA

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

Verified Apr 2026

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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.

References

1.2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease (2020)

Drug

Class

Adult

Paediatric

Notes