PassFinals
Cardiovascular

Valvular Heart Disease

Valvular heart disease presents through murmurs, symptoms or imaging; identify severity, urgency, mechanism and the need for specialist valve-team review.

In a nutshell

A murmur is a clue, not a diagnosis. Use symptoms/red flags to triage, echo to define lesion/severity, and the valve team to decide intervention and follow-up.

Classic presentation

Incidental murmur or exertional breathlessness: classify timing, arrange echo and assess symptoms, function, rhythm and pulmonary pressure.

Key points

  • Ejection systolic, pansystolic, early diastolic and mid-diastolic murmurs suggest different lesions, but echo is required for grading.
  • Exertional syncope or severe symptoms with a murmur warrants urgent assessment; pulmonary oedema or shock is an emergency.
  • Moderate/severe disease and bicuspid aortic valve need specialist assessment.
  • Symptomatic severe disease generally needs intervention assessment; timing is lesion-specific.
  • Assess AF, HF, pulmonary hypertension, endocarditis, pregnancy and aortopathy as relevant.
  • Routine endocarditis prophylaxis for most dental procedures is not recommended; oral health and safety-netting matter.
  • Post-intervention antithrombotic treatment and surveillance depend on prosthesis and other indications.

First-line investigation

TTE prompted by the murmur and clinical context.

Management

Recognise urgent presentations

  • Pulmonary oedema, shock, severe symptoms or exertional syncope with a murmur needs urgent assessment; consider acute MR, AR, endocarditis, infarction or dissection.1,4,3

Confirm with echocardiography

  • Use TTE to define lesion, mechanism, severity, ventricular response, pulmonary pressure and associated disease; escalate when needed.1,2

Treat complications

  • Manage congestion, HF, AF, thromboembolism and suspected endocarditis through relevant UK pathways.1,5,6

Refer for valve intervention

  • Refer symptomatic severe disease and selected asymptomatic severe disease with lesion-specific ventricular or haemodynamic triggers.1

Give prevention advice

  • Emphasise oral hygiene, explain that routine antibiotic prophylaxis is not recommended for most dental procedures, and give fever/deterioration safety-netting.6

Plan long-term surveillance

  • Use lesion-specific echo intervals and individualise post-intervention review according to prosthesis, residual disease, other valves and preference.1,2

Exam traps

  • Murmur volume does not reliably indicate severity.
  • Normal EF does not exclude important chronic regurgitation.
  • Do not apply a generic AF anticoagulation rule to moderate/severe MS or mechanical valves.
  • Do not give routine endocarditis antibiotics solely because a patient has a valve lesion.
  • A valve problem can be secondary to HF or ischaemia; mechanism matters.

Illustrations

Murmur map by valve lesionDiagram mapping each valve lesion to its murmur timing (systolic or diastolic), auscultation site and radiation: aortic stenosis, aortic regurgitation, mitral stenosis and mitral regurgitation.Npatchett, Wikimedia Commons · CC-BY-SA-4.0
Mitral regurgitation on Doppler echocardiographyContinuous-wave Doppler recording through a mitral regurgitation jet, with a colour Doppler inset, illustrating a regurgitant valve lesion that produces left-sided volume overload.Goleisureintl, Wikimedia Commons · CC-BY-4.0

Key sources

  1. NICE NG208: Heart valve disease presenting in adults (Referral, investigation, pharmacological management, intervention and follow-up recommendations)Published 17 Nov 2021 | Updated 24 Oct 2025
  2. BSE/BHVS: Clinical indications and triage for echocardiography in heart valve disease (UK consensus on referral, red flags and surveillance)Published 1 Aug 2024
  3. British Society of Echocardiography: Echocardiographic assessment of the mitral valve (UK assessment guideline for mitral stenosis and regurgitation)Published 1 Sept 2021
  4. British Society of Echocardiography: Echocardiographic assessment of aortic regurgitation (UK assessment guideline for acute and chronic aortic regurgitation)Published 28 Jan 2025
  5. NICE NG196: Atrial fibrillation: diagnosis and management (Anticoagulation recommendations and scope)Published 27 Apr 2021 | Updated 19 Jun 2024
  6. NICE CG64: Prophylaxis against infective endocarditis (Antibiotic prophylaxis and oral-health recommendations)Published 28 Mar 2008 | Updated 1 Sept 2015
  7. NICE NG208: Heart valve disease presenting in adults — overview (Current guideline status and update information)Published 17 Nov 2021 | Updated 24 Oct 2025

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.