The ACC and the American Heart Association have released a focused update of guidelines for the treatment of patients with valvular heart disease. The new guidance, which has been updated to reflect the latest research since the last guidelines were published in 2014, was published March 15 in the Journal of the American College of Cardiology.

Specifically, the focused update includes changes in indications for antibiotic prophylaxis for infective endocarditis, the use of direct oral anticoagulants among patients with atrial fibrillation and heart valve disease, indications for transcatheter aortic valve replacement (TAVR), surgical management of patients with primary and secondary mitral regurgitation, and management of patients with a heart valve prosthesis.

Of note, the focused update modifies some recommendations for surgical aortic valve replacement (SAVR) and TAVR based on the results of clinical trials. SAVR, for example, is recommended for people with advanced aortic stenosis who have low or intermediate risk of surgery for either symptoms or other indications of future problems. For patients with advanced aortic stenosis who have symptoms, such as shortness of breath and fatigue, and are at intermediate or high risk of surgery, the writing committee found that TAVR is a reasonable alternative to SAVR. They explain that the decision to undergo SAVR or TAVR should be a shared decision in consultation with the patient, surgeon and cardiologist to determine the best option based on the patient’s needs and preferences. The shared decision–making approach should also be used when considering replacing a faulty valve with either a mechanical or tissue valve.

In addition, among patients undergoing aortic or mitral valve replacement, the age range was expanded from 60 to 70 years of age to 50 to 70 years of age for the choice of either a mechanical or tissue valve. Mechanical were previously recommended for patients younger than 60 years old.

The authors have also clarified the previous recommendations regarding which patients with a risk of developing infective endocarditis should receive antibiotics before certain dental procedures. The guidelines now say that giving antibiotics to prevent bacterial infection is reasonable before dental procedures for people who have had previous valve surgery or previous infection of their valve or for patients who have certain types of congenital heart disease and were born with abnormal valves.

The focused update is intended to help health care providers prevent symptoms, disability and premature death in patients with valve disease. “A heart murmur often is detected on physical examination many years before symptoms appear and should prompt further evaluation with an echocardiogram. Careful periodic monitoring and medical therapy result in better long term outcomes because patients have valve replacement at the right time; not too soon and not too late,” said Catherine M. Otto, MD, FACC, co–chair of the writing committee and professor of medicine at the University of Washington in Seattle.