July 14, 2017
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ACC, AHA update guidelines on management of valvular heart disease

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The American College of Cardiology and the American Heart Association have released updated recommendations on the treatment of patients with valvular heart disease to reflect the latest research published since the 2014 guidelines.

“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. We also looked across the spectrum of valvular heart disease and found other updates were needed as well,” Catherine M. Otto, MD, co-chair of the writing committee for the update and professor of medicine at the University of Washington in Seattle, told Cardiology Today’s Intervention.

The 2017 focused update of the guidelines, which has been simultaneously published in Circulation and the Journal of the American College of Cardiology, includes new or modified sections related to anticoagulation in atrial fibrillation; interventions in aortic stenosis; infective endocarditis; mitral regurgitation; and various issues related to prosthetic valves.

Otto said only updates and additions were published, and these updated sections should replace the corresponding sections in the original guidelines. Recommendations that were not updated remain the same as in the 2014 guidelines.

Anticoagulation in AF

The focused update includes several important changes as well as the introduction of new recommendations.

One new section, Otto said, addresses anticoagulation in patients with AF. The previous iteration of the guidelines states that the direct oral anticoagulants or novel oral anticoagulants were not tested in patients who did not have valve disease. However, those studies included many patients with valve disease, but it was not severe and did not require immediate surgery, according to Otto. When researchers conducted subanalyses of patients with valve disease in the large AF trials, results showed that direct oral anticoagulants are effective in patients with valve disease and AF.

“This new section states that it is appropriate to use a direct oral anticoagulant in people with AF and valve disease unless the patient has a prosthetic mechanical valve or rheumatic mitral stenosis,” Otto said. “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.”

Surgical AVR in aortic stenosis

Another important update relates to aortic stenosis, according to Otto. The indications for which patients should undergo surgical AVR did not change, but the writing committee underscored the need to individualize valve selection.

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“We are beginning to extend the indication for transcatheter valves from patients who have a high risk of surgery down into the intermediate-risk group. 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,” Otto said.

In intermediate-risk patients, other factors, such as vascular access, comorbid conditions that may affect the risk of either intervention, expected functional status and survival after surgical AVR, and patient preferences, should be considered when deciding whether surgical AVR or TAVR is best, according to the guidelines.

Additionally, the updated guidelines state that when choosing between a mechanical or bioprosthetic valve, it is reasonable to consider bioprosthetic valves in patients aged at least 50 years as opposed to those aged at least 60 years, as recommended in the previous guidelines.

“This change in recommendation is based on improved durability of the currently available bioprosthetic valves as well as the publication of some large database studies showing that outcomes are similar with either type of valve,” Otto said.

A rapidly moving field

Otto said clinicians should follow the guidelines, which are fairly conservative, unless the patient is involved in a randomized trial. However, it is important that clinicians also keep an eye on the literature, particularly in relation to the choice of valve in patients with severe aortic stenosis requiring valve replacement, as the field is constantly evolving.

Otto also said this update is informed by the latest available data, but perhaps more can be done to ensure all guidelines are keeping pace with the research.

“As a group of professionals, we need to come up with a way to continuously update guidelines because cardiology is a rapidly moving field. We have new, important studies coming out frequently,” she said. “Obviously, we don’t want to overreact to one individual study in terms of changing guidelines, but updating on a 5-year schedule is much too slow for bringing state-of-the-art, evidence-based medicine to our patients.” – by Melissa Foster

For more information:

Catherine M. Otto, MD, can be reached at otto@cardiology.washington.edu.

Disclosures: Otto reports no relevant financial disclosures. Please see the guideline update for all other authors’ relevant financial disclosures.