Heart valve disease presenting in adults: investigation and management

1 Monitoring when there is no current need for intervention

What is the most clinically and cost-effective monitoring (type and frequency of test) for adults with asymptomatic mild or moderate heart valve disease (aortic stenosis, aortic regurgitation, mitral stenosis, mitral regurgitation and tricuspid regurgitation) and no current need for intervention?

2 Interventions for tricuspid regurgitation

What is the most clinically and cost-effective management strategy for adults with tricuspid regurgitation?

3 Interventions for a failed valve

What is the clinical and cost effectiveness of transcatheter intervention compared with surgical redo intervention for adults with failing biological prosthetic tricuspid valves or failing repaired native tricuspid valves when either procedure is suitable?

4 Monitoring after an intervention

What is the most clinically and cost‑effective timing, nature and frequency of follow up for different types of valve interventions, including repair and replacement with tissue or mechanical valves?

5 Information and advice

What are the information and advice needs of all adult age groups with heart valve disease of all severities and stages?

6 Indications for interventions – stress testing or echocardiography

What is the prognostic value of severe mitral regurgitation unmasked on exercise echocardiography in adults with symptomatic non‑severe mitral regurgitation at rest?

What is the prognostic value of parameters observed on exercise stress testing and exercise stress echocardiography in asymptomatic severe aortic regurgitation?

7 Indications for interventions – CT or MRI

In adults with aortic or primary mitral regurgitation in whom the need for intervention is unclear after echocardiography, what is the prognostic value and cost effectiveness of cardiac MRI to assess the severity of valvular regurgitation?

In adults with aortic or mitral regurgitation in whom the need for intervention is unclear after echocardiography, what is the prognostic value and cost effectiveness of left ventricular ejection fraction (LVEF) measured on cardiac MRI to assess the need for intervention?

In adults with asymptomatic severe aortic stenosis what is the prognostic value and cost effectiveness of LVEF measured on cardiac MRI to assess the need for intervention?

In adults with asymptomatic severe tricuspid regurgitation what is the prognostic value and cost effectiveness of cardiac MRI for assessment of the right ventricle to assess the need for intervention?

8 Indications for interventions – global longitudinal strain

In adults with severe heart valve disease what is the prognostic value and cost effectiveness of global longitudinal strain to assess the need for intervention?

In adults with asymptomatic, severe aortic regurgitation or mitral regurgitation what is the prognostic value and cost effectiveness of B‑type natriuretic peptide (BNP) to assess the need for intervention?

9 Pharmacological management for adults with heart valve disease

What is the clinical and cost effectiveness of ACE inhibitors, angiotensin II receptor antagonists, beta‑blockers and diuretics for adults with severe aortic stenosis?

What is the clinical and cost effectiveness of ACE inhibitors, angiotensin II receptor antagonists, beta‑blockers and calcium channel blockers, including compared with placebo, for adults with aortic regurgitation?

What is the clinical and cost effectiveness of ACE inhibitors, angiotensin II receptor antagonists, beta‑blockers and diuretics for adults with primary severe mitral regurgitation?

What is the clinical and cost effectiveness of beta‑blockers for adults over 75 years with non‑rheumatic/calcific mitral stenosis, in both sinus rhythm and atrial fibrillation?

What is the clinical and cost effectiveness of pharmacological management of heart failure for adults with heart failure and severe aortic stenosis, severe aortic regurgitation or severe mitral regurgitation?

10 Monitoring when there is no current need for intervention

What is the most clinically and cost‑effective monitoring strategy (type and frequency of test) for adults with asymptomatic severe heart valve disease (aortic regurgitation, mitral stenosis, mitral regurgitation or tricuspid regurgitation) and no current indication for intervention?

What is the most clinically and cost‑effective monitoring strategy (type and frequency of test) for adults with symptomatic moderate heart valve disease (aortic stenosis, aortic regurgitation, mitral stenosis, mitral regurgitation and tricuspid regurgitation) and no current indication for intervention?

11 Interventions

What is the most clinically and cost‑effective management strategy for adults with calcific mitral stenosis and an indication for intervention?

12 Anticoagulation and antiplatelet therapy

What is the clinical and cost effectiveness of single or dual antiplatelet therapies or anticoagulants compared with placebo after transcatheter or surgical valve replacement (implantation) with biological prosthesis and after valve repair?

In adults with biological valve replacement, what effect does anticoagulation or antiplatelet therapy have on long-term valve function and outcomes?

13 Repeat interventions

What is the clinical and cost effectiveness of transcatheter intervention compared with surgical redo intervention for adults with failing biological prosthetic aortic valves when either procedure is suitable?

What is the clinical and cost effectiveness of transcatheter intervention compared with surgical redo intervention for adults with failing biological prosthetic mitral valves when either procedure is suitable?