Outlining the 2021 ESC Guidelines for the Management of Valvular Heart Disease
In 2021, the European Society of Cardiology (ESC) issued updated guidelines on several topics, including cardiovascular disease prevention, cardiac pacing and cardiac resynchronisation therapy, and heart failure (HF). An overview of the newly revised recommendations for acute and chronic HF can be found in the latest issue of EMJ Cardiology. Based on a session presented during the 2021 ESC Congress, this feature provides insights into the management of HF with reduced ejection fraction, the diagnosis and treatment of HF with mildly reduced and preserved ejection fraction, and the management of comorbidities associated with HF. In addition to the above recommendations, the ESC also provided updated clinical guidance for addressing valvular heart disease (VHD).
VHD is a common condition characterised by damage or a defect in one or more of the four heart valves: aortic, mitral, pulmonary, and tricuspid. This can be caused by either valvular stenosis or regurgitation. In the USA, approximately 2.5% of the population has VHD. Notably, prevalence increases with age, rising from 0.7% in individuals aged 18–44 years to around 13.0% in those aged 75 years and older. Moderate or severe VHD is associated with an impaired quality of life; increased hospitalisation; and can progress to HF, arrhythmias, or death. Clearly, VHD poses a substantial public health problem, especially in an ageing society. Guideline-derived medical treatment can play a major role in reducing morbidity and mortality and should, therefore, be used.
Since publication of the 2017 ESC and European Association for Cardio-Thoracic Surgery (EACTS) guidelines on VHD management, new evidence has emerged, necessitating a review of the recommendations in 2021.
In a press release, Alec Vahanian, ESC task force chairperson and lead author of the guidelines, explained one crucial component of the new recommendations: “VHD is too often undetected, and the guidelines stress the importance of clinical examination as the first step in diagnosis.” Vahanian added: “Non-invasive evaluation using echocardiography first, and other cardiac imaging techniques when needed, is essential to assess severity and catheterisation should only be used when imaging is inconclusive.”
In terms of atrial fibrillation management in people with native VHD, there were two significant developments in the new guidelines. Left atrial appendage occlusion should now be considered to reduce the risk of thromboembolism in patients with atrial fibrillation and a CHA2DS2VASc score of ≥2 for those who are undergoing valve surgery. This was awarded a Class IIa level of evidence. For stroke prevention in individuals with atrial fibrillation who are eligible for oral anticoagulation, non-vitamin K antagonist oral anticoagulants are now the preferred treatment over vitamin K antagonists in patients with aortic stenosis as well as aortic and mitral regurgitation. This was assigned a Class I level of evidence.
Regarding asymptomatic patients with aortic regurgitation, surgery is now recommended (Class I) in people with a left ventricular end-systolic diameter (LVESD) of >50 mm or >25 mm/m2 body surface area (in patients with small body size), or in people with a resting left ventricular ejection fraction of ≤50%. Additionally, a Class IIb level of evidence was awarded to the use of aortic valve repair in selected patients at experienced centres and when durable results are expected.
Further updates concerned intervention in patients with aortic stenosis. For instance, surgical aortic valve replacement is recommended in individuals less than 75 years old with a Society of Thoracic Surgeons (STS) score of <4% (i.e., low risk), or in those who are operable and unsuitable for transfemoral transcatheter aortic valve implantation (TAVI). Conversely, in older patients (over the age of 75 years) and those who are high-risk (an STS score of >8%) or unsuitable for surgery, TAVI is recommended. These have both been assigned a Class I level of evidence. Interestingly, non-transfemoral TAVI may now be considered (Class IIb) in people who are inoperable for surgical aortic valve replacement and unsuitable for transfemoral TAVI.
Intervention in severe primary mitral regurgitation was also addressed. Specifically, surgery should be considered (Class IIa) in asymptomatic patients with preserved left ventricular function (LVESD: <40 mm; left ventricular ejection fraction: >60%) and atrial fibrillation secondary to mitral regurgitation or pulmonary hypertension (systolic pulmonary arterial pressure at rest: >50 mmHg).
Finally, valve surgery or intervention is now recommended (Class I) in people with severe secondary mitral regurgitation who remain symptomatic despite guideline-directed medical therapy, including cardiac resynchronisation, if indicated. Importantly, this has to be decided by a structured and collaborative heart team.
Also of note are the 2020 ESC guidelines on exercise and sports participation in patients with cardiovascular disease. These have the distinction of being the first of their kind and are the focus of another feature published in EMJ Cardiology.
To summarise, regularly reviewing and, where necessary, updating clinical practice guidelines is imperative in order to ensure optimal decision-making by health practitioners. Ultimately, this will facilitate improvements in the quality of care received by patients.