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Treating heart valve disease

Years ago, rheumatic fever was the main cause of heart valve disease. Thanks to improved public health and better housing, this has all but disappeared in developed countries like the UK.

But valve disease, when one or more of the heart’s valves is thickened or damaged, affecting the flow of blood through the heart, remains a serious problem.

These days it is caused mainly by degenerative diseases resulting in aortic stenosis and mitral regurgitation, which tend to increase with age. Research in the United States suggests a prevalence of around 13 per cent in those aged 75 and over.

Yet valve disease is often universally undetected, underinvestigated and undertreated. A working group on how to improve the care of heart valve disease was recently convened by the British Heart Valve Society (BHVS) to try and hammer out some recommendations to improve the situation.

BHVS president Professor John Chambers explains: “One reason for heart valve disease not being detected is that it often causes no symptoms at first so the patient doesn’t know to visit his or her GP. But it may also be underdiagnosed because GPs do not always know how common valve disease now is. They may not listen to the heart or think of valve disease when a patient reports breathlessness or chest tightness on exertion.

“If a patient comes into a GP’s surgery with a detectable heart murmur and complaining of breathlessness, then alarm bells should be ringing and that patient should be referred for an echocardiogram. But in some cases this is simply not happening.”

For some elderly patients, when conventional surgery is too high risk or not technically suitable, there is now the possibility of a TAVI transcatheter procedure

It can be hard for GPs to pick up everyone who may have valve disease because they have very little time in which to assess a patient. Listening to the heart with a stethoscope is hard and not always reliable. “The best way to pick up heart valve disease is with an ultrasound scan of the heart – echocardiogram – and we believe these need to be more widely available,” says Professor Chambers.

Many GPs who have a special interest in valve disease are taking the lead and developing community-based clinics where patients can have an echocardiogram, and can be followed up and referred appropriately.

“This is good but it relies on enthusiasts with a particular interest in valve disease and provides a patchy service. Our feeling is that we need a systematic national approach agreed by government,” says Professor Chambers.

Some experts in the field are concerned that any “privatisation” of services within the NHS would mean diagnostic services are tendered out to the cheapest bidder who may not adhere to the high standards of the NHS.

“There is a distinct danger that substandard echocardiograms with a poor-quality machine may be done and that standards will be compromised. The echocardiogram must also be backed up by the correct medical advice if an abnormality is found,” says Professor Chambers.

“It is vital that everyone in the commissioning process is aware that rigorous quality standards exist which absolutely have to be followed by any provider.”

Once detected, valve disease must be managed properly. The BHVS is calling for the development of nationwide specialist heart valve clinics where initial assessment and subsequent surveillance of valve disease can be delivered. The correct timing of surgery can then be determined and the patient referred to the appropriate surgeon.

“The organisation of care for valve disease could be improved and there is growing international consensus that specialist valve clinics will improve care and reduce costs,” says Professor Chambers.

A study in Vienna recently showed that patients with severe aortic stenosis have their symptoms detected sooner and therefore their symptoms are less severe when they are seen within a heart valve clinic compared to those referred from other clinics.

Severe symptomatic heart valve disease is fatal if left untreated, but timely intervention can prolong survival. “We need to increase our use of valve repair techniques, particularly for some types of mitral regurgitation,” says Professor Chambers. There is also a need to improve access to aortic valve surgery for which the uptake rates vary widely across the country.

“Access is a particular problem for the elderly. Many with severe aortic stenosis, who would do well with surgery, are not being referred to a surgeon largely because of age alone,” Professor Chambers claims.

For some elderly patients, when conventional surgery is too high risk or not technically suitable, there is now the possibility of a TAVI transcatheter procedure, which again is not equally available in all parts of the country. “We don’t want any artificial barriers to patients getting the correct treatment,” he says.

The other crucial component in ensuring detection of valve disease is to raise its profile. That means educating doctors and patients alike, and the BHVS has developed an information package for patients on their website. It is also at the forefront in providing training for doctors, nurses and sonographers, including a new e-learning programme.

Training and education is part of the wider aim for valve clinics. “Within the clinics we can train general cardiologists and other doctors in specialist valve disease, and keep colleagues up to date with developments,” says Professor Chambers.

“Finally we need to introduce guidelines on a national level so that everyone understands the importance of detecting valve disease and how best to treat it.

“The BHVS believes valve disease should be the next cardiac pathology to receive national attention following the success of previous health initiatives directed at heart failure and coronary disease.”

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