People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.
Consider an echocardiogram for adults with a murmur and no other signs or symptoms if valve disease is suspected based on:
the nature of the murmur
family history
age (especially if over 75), or
medical history (for example, a history of atrial fibrillation).
Offer an echocardiogram to adults with a murmur if valve disease is suspected (based on the nature of the murmur, family history, age or medical history) and they have:
signs (such as peripheral oedema) or symptoms (such as angina or breathlessness) or an abnormal ECG, or
an ejection systolic murmur with a reduced second heart sound but no other signs or symptoms.
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on referral for echocardiography.
Full details of the evidence and the committee's discussion are in evidence review A: symptoms and signs indicating need for echocardiography or direct referral to a specialist.
If valve disease is suspected (based on the nature of the murmur, family history, age or medical history):
Offer urgent (within 2 weeks) specialist assessment that includes echocardiogram or if not available an urgent echocardiogram alone to adults with a systolic murmur and exertional syncope.
Consider urgent (within 2 weeks) specialist assessment that includes echocardiogram for adults with a murmur and severe symptoms (angina or breathlessness on minimal exertion or at rest) thought to be related to valvular heart disease.
For guidance on referral and assessment for adults with murmur and non-exertional syncope, follow the recommendations in the NICE guideline on transient loss of consciousness ('blackouts') in over 16s.
For guidance on referral and assessment for adults with breathlessness but no murmur, follow the recommendations in the NICE guideline on chronic heart failure in adults.
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on referral for urgent specialist assessment or urgent echocardiography.
Full details of the evidence and the committee's discussion are in evidence review A: symptoms and signs indicating need for echocardiography or direct referral to a specialist.
Be aware that mild valve disease is common and rarely progresses to become clinically significant.
Offer referral to a specialist to:
adults with moderate or severe valve disease of any type
adults with bicuspid aortic valve disease of any severity (including mild valve disease).
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on referral to a specialist after echocardiography.
Full details of the evidence and the committee's discussion are in evidence review B: indications for referral to a specialist following echocardiography.
Be aware that most women with valve disease can have a pregnancy without complications.
Offer advice on the implications of treatment choices on any future pregnancy to women who need heart valve intervention.
Offer advice on family planning to women with severe valve disease, particularly aortic and mitral stenosis.
Refer pregnant women or women who are considering a pregnancy to a cardiologist with expertise in the care of pregnant women, if they have any of the following:
moderate or severe valve disease
bicuspid aortic valve disease of any severity (including mild disease) and associated aortopathy
a prosthetic valve.
Refer whether they have symptoms or not.
Consider seeking specialist advice on the choice of replacement valve if heart valve replacement surgery is being considered for women of childbearing potential.
For guidance on intrapartum care, follow the recommendations on heart disease in the NICE guideline on intrapartum care for women with existing medical conditions or obstetric complications and their babies.
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on information, referral and specialist assessment for pregnant women and women considering a pregnancy.
Full details of the evidence and the committee's discussion are in evidence review A: symptoms and signs indicating need for echocardiography or direct referral to a specialist.
Consider a beta-blocker for adults with moderate to severe mitral stenosis and heart failure.
When adults with heart valve conditions and heart failure also have left ventricular dysfunction, refer to the NICE guideline on chronic heart failure in adults.
For a short explanation of why the committee made these recommendations and how they might affect practice, see rationale and impact section on pharmacological management of heart failure in heart valve disease.
Full details of the evidence and the committee's discussion are in evidence review C: pharmacological management.
Offer an intervention to adults with symptomatic severe heart valve disease.
For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on indications for interventions.
Full details of the evidence and the committee's discussion are in evidence review H: transcatheter intervention, surgery or conservative management in heart valve disease.
Consider referring adults with asymptomatic severe aortic stenosis for intervention, if suitable, if they have any of the following:
Vmax (peak aortic jet velocity) more than 5 m/s on echocardiography
aortic valve area less than 0.6 cm2 on echocardiography
left ventricular ejection fraction (LVEF) less than 55%
B‑type natriuretic peptide (BNP) or N-terminal proBNP (NT-proBNP) level more than twice the upper limit of normal
symptoms unmasked on exercise testing.
Consider referring adults with symptomatic low‑gradient aortic stenosis with LVEF less than 50% for intervention if during dobutamine stress echocardiography the aortic stenosis is shown to be severe by:
a mean gradient across the aortic valve that increases to more than 40 mmHg and
an aortic valve area that remains less than 1 cm2.
Consider measuring aortic valve calcium score on cardiac CT if the severity of symptomatic aortic stenosis is uncertain.
Offer enhanced follow up (for example, more frequent reviews) and further assessment (for example, stress echocardiography) to monitor the need for intervention if mid‑wall fibrosis is detected on cardiac MRI in adults with severe aortic stenosis.
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on indications for interventions for adults with aortic stenosis.
Full details of the evidence and the committee's discussion are in:
Consider referring adults with asymptomatic severe aortic regurgitation for intervention, if suitable, if they have either of the following:
LVEF less than 55% or
end systolic diameter (ESD) of more than 50 mm or end systolic diameter index (ESDI) more than 24 mm/m2 on echocardiography.
For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on indications for interventions for adults with aortic regurgitation.
Full details of the evidence and the committee's discussion are in evidence review D: indications for intervention.
Consider referring adults with asymptomatic severe primary mitral regurgitation for intervention, if suitable, if they have any of the following:
LVEF less than 60%
ESD more than 45 mm or ESDI more than 22 mm/m2 on echocardiography or
an increase of systolic pulmonary artery pressure to more than 60 mmHg on exercise testing.
When making decisions about referral for surgery, take into account the suitability of the valve for repair and the presence of atrial fibrillation or systolic pulmonary artery pressure of more than 50 mmHg on echocardiography at rest.
For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on indications for intervention for adults with mitral regurgitation.
Full details of the evidence and the committee's discussion are in evidence review D: indications for intervention and evidence review E: stress testing and stress echocardiography in determining need for intervention.
Offer clinical review every 6 to 12 months, with an echocardiogram, to adults with asymptomatic severe valve disease if an intervention is suitable but not currently needed. Base the frequency of the review on echocardiography findings and shared decision making with the patient.
Consider echocardiographic assessment every 3 to 5 years for adults with mild aortic or mitral stenosis.
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on monitoring where there is no current need for intervention.
Full details of the evidence and the committee's discussion are in evidence review G: monitoring of people with heart valve disease and no current indication for intervention.
See the recommendations on indications for interventions.
Discuss the possible benefits and risks of interventions with adults who have an indication for valve intervention. Include in the discussion:
the benefits to quality of life (both in the short and long term)
prosthetic valve durability
the risks associated with the procedures
the type of access for surgery (median sternotomy, minimally invasive surgery or, for people at high surgical risk, transcatheter)
the possible need for other cardiac procedures in the future.
Follow the recommendations in the NICE guidelines on shared decision making and patient experience in adult NHS services and base decisions on the type of intervention on patient characteristics and preferences.
When surgery is agreed, base the decision on the type of surgery (median sternotomy or minimally invasive surgery) on patient characteristics and preferences. If minimally invasive surgery is the agreed option and is not available locally, refer the person to another centre.
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on decisions about interventions.
Full details of the evidence and the committee's discussion are in evidence review H: transcatheter intervention, surgery or conservative management in heart valve disease.
For NHS England and NHS Improvement's position on transcatheter aortic valve implantation for people at low or intermediate surgical risk, see the implementation strategy for transcatheter aortic valve implantation.
Offer surgery, if suitable (by median sternotomy or minimally invasive surgery), as first-line intervention for adults with severe aortic stenosis, aortic regurgitation or mixed aortic valve disease and an indication for surgery who are at low or intermediate surgical risk. TAVI is not cost effective for people at low or intermediate surgical risk at the current list price.
Offer TAVI, if suitable, to adults with non-bicuspid severe aortic stenosis who are at high surgical risk or if surgery is unsuitable.
See the recommendations on using TAVI in the NICE interventional procedures guidance on transcatheter aortic valve implantation for aortic stenosis, including entering the details of all people undergoing TAVI into the UK TAVI registry. See also the NICE interventional procedures guidance on sutureless aortic valve replacement in aortic stenosis and balloon valvuloplasty for aortic valve stenosis.
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on interventions for aortic valve disease.
Full details of the evidence and the committee's discussion are in evidence review H: transcatheter intervention, surgery or conservative management in heart valve disease.
Consider transcatheter valvotomy for adults with rheumatic severe mitral stenosis, if the valve is suitable for this procedure.
Offer surgical mitral valve replacement to adults with rheumatic severe mitral stenosis if transcatheter valvotomy is unsuitable.
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on interventions for mitral stenosis.
Full details of the evidence and the committee's discussion are in evidence review H: transcatheter intervention, surgery or conservative management in heart valve disease.
Offer surgical mitral valve repair (by median sternotomy or minimally invasive surgery) to adults with severe primary mitral regurgitation and an indication for repair, if surgery is suitable.
Offer surgical mitral valve replacement (by median sternotomy or minimally invasive surgery) to adults with severe primary mitral regurgitation and an indication for surgery, if the valve is not suitable for repair and surgery is suitable.
Consider transcatheter edge-to-edge repair, if suitable, for adults with severe primary mitral regurgitation and symptoms, if surgery is unsuitable.
See NHS England's clinical commissioning policy on percutaneous mitral valve leaflet repair for primary degenerative mitral regurgitation in adults and the NICE interventional procedures guidance on percutaneous mitral valve leaflet repair for mitral regurgitation and thoracoscopically assisted mitral valve surgery.
Consider surgical mitral valve repair (by median sternotomy or minimally invasive surgery) for adults with severe secondary mitral regurgitation who are having cardiac surgery for another indication, if surgery is suitable.
Consider surgical mitral valve replacement (by median sternotomy or minimally invasive surgery) for adults with severe secondary mitral regurgitation who are having cardiac surgery for another indication, if the valve is not suitable for repair and surgery is suitable.
Offer medical management to adults with heart failure and severe secondary mitral regurgitation, if surgery is unsuitable.
Consider transcatheter mitral edge-to-edge repair for adults with heart failure and severe secondary mitral regurgitation, if surgery is unsuitable and they remain symptomatic on medical management.
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on interventions for mitral regurgitation.
Full details of the evidence and the committee's discussion are in evidence review H: transcatheter intervention, surgery or conservative management in heart valve disease.
Consider surgical tricuspid valve repair at the time of mitral valve surgery when tricuspid regurgitation is moderate or severe.
Consider surgical tricuspid valve repair at the time of aortic valve surgery when tricuspid regurgitation is severe.
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on interventions for tricuspid regurgitation.
Full details of the evidence and the committee's discussion are in evidence review H: transcatheter intervention, surgery or conservative management in heart valve disease.
Consider transcatheter or redo surgical intervention for adults with severe aortic degeneration of a biological prosthetic valve and symptoms. Take into account the following factors to inform a shared decision about the choice of intervention:
the short- and long-term benefits
type of valve dysfunction and prosthesis
the risks associated with the procedure
the possible need for other cardiac procedures in the future.
See the NICE interventional procedures guidance on using transapical transcatheter mitral valve-in-valve implantation for a failed surgically implanted mitral valve bioprosthesis, transapical transcatheter mitral valve-in-ring implantation after failed annuloplasty for mitral valve repair and valve-in-valve TAVI for aortic bioprosthetic dysfunction.
For a short explanation of why the committee made this recommendation and how it might affect practice, see rationale and impact section on repeat intervention.
Full details of the evidence and the committee's discussion are in evidence review I: repeat intervention for failure of biological or repaired valves.
Do not offer anticoagulation after surgical biological valve replacement unless there are other indications for anticoagulation.
Consider aspirin, or clopidogrel if aspirin is not tolerated, after TAVI.
If people have other indications for anticoagulation or antiplatelet therapy, follow the recommendations in the NICE guidelines on atrial fibrillation and acute coronary syndromes.
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on anticoagulation and antiplatelet therapy.
Full details of the evidence and the committee's discussion are in evidence review J: anticoagulant and/or antiplatelet therapy for biological prosthetic valves and after valve repair.
Base decisions on the frequency and type of monitoring for adults who have had an intervention (valve repair or replacement) for valve disease on:
durability of the prosthetic valve or durability of the repair
the presence of another condition, including other heart disease
residual valve abnormality or consequences of the procedure, for example, paravalvular leak
concerns about abnormal function of the prosthetic valve
the patient's wishes.
Advise people and their family members or carers (as appropriate) to seek advice if the heart condition deteriorates.
For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on monitoring after an intervention.
Full details of the evidence and the committee's discussion are in evidence review K: monitoring in people with repaired or replaced heart valves.
Follow the NICE guideline on shared decision making and the recommendations in the NICE guideline on patient experience in adult NHS services on:
involvement of family members and carers
communication
information
tailoring healthcare services.
Consider providing a point of contact for accessing specialist advice between appointments.
Be aware of the psychological impact on the person receiving a diagnosis of valve disease, whether or not they have symptoms. Consider the person's needs for additional information and support.
Provide information and advice to adults with valve disease about:
the expected progression and prognosis of their condition, including the likely length of an asymptomatic stage
any need for intervention, including the type of intervention
pregnancy, if appropriate
the possible effects of other conditions on long-term outcomes
rehabilitation and long‑term outcomes
palliative care, if appropriate, including how to access this.
Provide information and support to young adults about transition from paediatric to adult services, in line with the NICE guideline on transition from children's to adults' services for young people using health or social care services.
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on information and advice.
Full details of the evidence and the committee's discussion are in evidence review L: information and advice.
This section defines terms that have been used in a particular way for this guideline.
Degenerated covers progressive degeneration and does not include failure of the valve due to endocarditis or thrombosis.
This is calculated using EuroSCORE II. People have low surgical risk if they score less than 4%, intermediate risk if they score between 4% and 8% and high risk if they score more than 8%.
Severity of valve disease is defined in line with the British Society of Echocardiography guidelines on the assessment of aortic stenosis, the tricuspid and pulmonary valves, and mitral valve disease.
This could include assessment and advice from a cardiologist with expertise in heart valve disease, a multidisciplinary team or a heart valve clinic.
Suitability for transcatheter aortic valve implantation (TAVI) depends on:
an appropriate access for inserting the TAVI catheter
the morphology of the valve, aortic root and ascending aorta
the degree and distribution of calcium in the aortic valve.
It is an option for:
All people expected to have an unacceptably high risk of mortality or morbidity as a result of surgery (for example, because of a risk of infection in people who are immunosuppressed). See also the definition of high risk of surgery according to EuroSCORE II.
All people expected to have unacceptably strenuous and prolonged recovery from surgery and an extended need for rehabilitation because of frailty, reduced mobility, or musculoskeletal conditions.
All people with low life expectancy, either because of their age or because they have life-limiting comorbidities.
Suitability for transcatheter edge-to-edge repair depends on:
the morphology of the person's valve
the feasibility of using transoesophageal echocardiography to guide the procedure
the person's fitness for general anaesthesia.