Diagnosis and management of heart failure due to valvular heart disease
Jim Newton
Consultant cardiologist
Oxford University Hospitals
Outline
• Background
• Clinical cases
• Summary of guidelines
• Areas for development
BACKGROUND
How many people >75 have moderate or severe valve disease?
1. 2%
2. 13%
3. 20%
4. 30%
5. 50%
Prevalence of moderate or severe valvular heart disease(%)
How many people 75-84 will there be in 2018?
1. 0.5 million
2. 2 million
3. 4 million
4. 8 million
5. 10 million
Potential scale of the problem
• 4 million aged 75 – 84
• Overall rate of significant valve disease = 13%
• Total number of patients ~ 520,000
How many patients admitted with heart failure have valve disease
1. 29%
2. 39%
3. 49%
4. 59%
Aetiology of heart failure
Aetiology %
Ischaemic heart disease 68
Moderate or severe valve disease 29
Dilated cardiomyopathy 3
How many patients with moderate or severe valve disease are dead at 5 years?
1. 7%
2. 17%
3. 21%
4. 25%
5. 30%
Mortality of valve disease
Do we know how to manage them?
Why do we need guidelines?
Why do we need guidelines?
Why do we need guidelines?
• Up to 49% of patients with symptomatic valvular heart disease do not receive surgical therapy
• Elderly patients with comorbidities
• Complex decision making
Background
• 13% >75 years have moderate or severe valve disease
• 29% of heart failure is due to valve disease
• 5 year survival with valve disease is poor
• Large proportion denied surgery
CLINICAL CASE 1
Making the diagnosis
• 75 year old male
• Hypertensive ex-smoker
• Progressive dyspnoea for 6 weeks
• Now significantly limited
• Examination reveals a systolic murmur
• ECG demonstrates left ventricular hypertrophy
How many patients referred for an echo for a murmur have valve disease?
1. 100%
2. 80%
3. 60%
4. 40%
5. 20%
Echocardiography
Echocardiography
Diagnosis made
• Severe aortic stenosis
• Good left ventricular systolic function
• No other valvular heart disease
What is best evidence based therapy?
1. Loop diuretic
2. Beta blocker
3. ACE inhibitor
4. Spironolactone
5. Statins
6. Other
Medical therapy in aortic stenosis
• No medical therapy is able to improve outcome
• Early intervention is required
• No role for statin treatment
Lessons
• Symptoms = intervention
• Heart failure therapy can reduce symptoms
• Even if improve on treatment still refer
• If any possibility of symptoms then refer
CLINICAL CASE 2
Chain of communication
• 72 year old female
• No comorbidities or past medical history
• Significant dyspnoea over 48 hours
• Awakes in night very breathless
• Seen by GP next morning
• In heart failure – referred to admissions unit
Examination
• In established heart failure
• Breathless at rest
• Sinus tachycardia
• Congestion on CXR
• Loud ejection systolic murmur
• Slow rising pulse
Investigations
• Small Troponin rise
• Widespread static ST changes on ECG
• Borderline elevation in creatinine
Management
• Intravenous diuretics
• Coronary angiography
• Echocardiography
Echocardiography
Echocardiography
Echocardiography
48 hours later
• Significant improvement in symptoms
• Normal coronary arteries
• Discharged home on oral diuretics
• GP asked to review and refer to cardiology OPD
Was that appropriate management?
1. Yes
2. No
2 weeks later
• Seen by GP
• Mildly breathless
• Referred to cardiology urgently
4 weeks later
• Due to be seen next week
• Sudden onset acute dyspnoea
• Readmitted in established heart failure
Currently
• Ongoing intravenous diuretic therapy
• Renal impairment
• Secondary respiratory infection
• Inpatient surgery when optimised
Lessons
• Patients presenting acutely need urgent treatment
• Medical therapy can mask severity
• Critical aortic stenosis is potentially lethal
• Early surgery preferable
CLINICAL CASE 3
History
• 85 year old male
• Prior coronary artery bypass grafting
• Renal impairment
• Probable COPD – on inhaler therapy
• Recent attendances with increasing dyspnoea
• Progressive peripheral oedema
• Cardiomegaly on chest X-ray
How accurate is cardiomegaly on a CXR?
1. 95%
2. 85%
3. 75%
4. 65%
5. 55%
Management
• Diuretic introduced with improvement
• No murmur heard
• Relapses few weeks later
Where would you refer?
1. Heart failure clinic
2. General cardiology clinic
3. Echocardiography
4. Respiratory
5. Do not refer
Echocardiography
Echocardiography
Echocardiography
Echocardiography
Management
• Severe aortic stenosis
• Severe LV dysfunction
• Moderate mitral regurgitation
• Prior bypass surgery and poor lungs
What options would you discuss?
1. Heroic re-do surgery
2. Palliative care
3. Referral to heart team
Seen by heart team
• Myocardium remains viable
• Anatomical suitability for transcatheter aortic valve implantation
• Mitral regurgitation secondary to LV dilation
• Pulmonary function reasonable
TAVI
Outcome
• Successful TAVI procedure
• Improvement to NYHA II within 6 weeks
• Follow up imminent
Lessons
• High risk patients should still be referred
• Transcatheter treatments evolving
• 1 year survival post TAVI of 90%
CLINICAL CASE 4
Reluctant customer
• 78 year old female
• Independent at home
• Doesn’t like to bother GP
• Not been attending social meetings recently
• Reluctantly admits to effort dyspnoea for over a year
• Also palpitations on effort
Clinical findings
• In atrial fibrillation
• Mild peripheral oedema
• Loud systolic murmur and dynamic pulse
• Clear lung fields
What are you suspecting?
1. Aortic stenosis
2. Mitral regurgitation
3. Aortic regurgitation
4. Left ventricular dysfunction
Initial management
• Rate control – beta blocker
• Thromboprophylaxis – Warfarin
• Symptom relief - diuretic
Would you refer now?
1. Yes
2. No – see how she gets on
Echocardiography
Echocardiography
Echocardiography
Attends cardiology OPD
• Does not feel symptoms are intrusive
• Reluctant to take medication
• Extremely reluctant to consider intervention
• Doesn’t know what all the fuss is about
Challenging management
• Phone call to GP to discuss strategy
• Information provided
• Regular follow up arranged
• Involvement of friends and family
Over the next year
• Progressive decline in activity levels
• One episode of acute dyspnoea
• Persuade to revisit options
• Referred to nicest surgeon
6 month later
• Successful mitral valve repair
• Rapid return to prior activities
• Now extremely grateful and actively fundraising for department
Lessons
• Severe MR can be tolerated for a long time
• Symptoms often very insidious and patients down play them
• Perseverance and team approach important
CLINICAL CASE 5
A real challenge
• 42 year old male
• Learning difficulties
• Long standing Crohn’s disease
• Admitted with severe PR bleeding
Progress
• Multiple endoscopies
• Intermittent bleeding
• Acute deterioration and major haemorrhage overnight
• Rapid transfusion and volume replacement
Subsequent developments
• Acute pulmonary oedema
• Required non-invasive ventilation and intravenous therapy for 24 hours
• Echocardiography on coronary care
Echocardiography
Echocardiography
Echocardiography
Does this man need surgery?
1. Yes
2. No
3. Probably – but not yet
Options
• Acute surgery difficult option
• No prior symptoms
• Careful liaison with all involved needed
Progress
• Bowel resection with cardiology support uneventful
• Recovered and discharged home
• Referred back early by GP as symptomatic
Referred for surgery
• Referred for mitral valve repair
• Prosthetic valve not an option
• Extensive counselling and discussion required
• Patient very dependent on GP opinion and advice
Surgery performed
• Mitral repair undertaken
• Complex bileaflet disease
• Difficult but successful
And then
• Readmitted 8 weeks post discharge
• Severely jaundiced and anaemic
• Not breathless
• Loud murmur
Unfortunately
• Small high velocity residual mitral regurgitation
• Severe haemolysis
• Requiring transfusion
Ultimately
• No progress with haematological input
• Jaundice intolerable
• Re-do surgery locally with single suture to close defect
• Symptom and jaundice free 3 months later
Lessons
• Valvular heart disease can be very complex
• Multidisciplinary approach key
• Be prepared to deal with complications
SUMMARY OF GUIDELINES
Summary of guidelines
• Comprehensive evaluation of cardiac and extra-cardiac conditions required
• Ensure consistency between clinical findings and investigations
• Decision making in high risk patients is difficult
Summary of guidelines
• Intervention is indicated in patients with severe valve disease and symptoms
• Transcatheter options are rapidly evolving
Area of contention
• Surgery should be considered in asymptomatic patients if:
– Low operative risk
– Rapid disease progression
– Progressive ventricular enlargement or LVH
– Likelihood of durable outcome
AREAS FOR DEVELOPMENT
Areas for development
• Major lack of evidence in valve disease
• Management of asymptomatic patients
• Novel medical therapy options
• Transcatheter treatment options
Conclusion
• Valve disease is common
• Valve disease causing heart failure is common
• Surgery best option if feasible
• Frequently complex and challenging patients