Update

Heart valve disease ‘facing diagnosis crisis’ over next 40 years

The prevalence of heart valve disease is set to soar in the next few decades – and GPs can help boost detection rates and ensure timely treatment, according to a top valve disease expert.

30 July 2018, by Siobhan Chan


 

Heart valve disease is going undetected across the UK despite warnings it will double in prevalence in the coming decades, according to a consultant cardiologist specialising in valve disease.

John Chambers, consultant cardiologist and professor of clinical cardiology at Guy’s and St Thomas’ NHS Foundation Trust, said GP awareness is vital to improving detection, as well as increased access to echocardiography to confirm diagnosis, while speaking at the British Cardiovascular Society Annual Conference in June 2018.

“The failure to detect valve disease is extremely high,” Professor Chambers said. “We need to bridge the gap of underdiagnosis, so that patients can access timely treatment.”

Listening to the heart

Around 1.5m people in the UK aged 65 or over are thought to have heart valve disease, including aortic stenosis and mitral regurgitation, and estimates suggest this will double by 2046 and rise to 3.3m in 2056, due to an ageing population1.

Timely treatment is important because the risk of dying from valve disease is greater the longer the patient lives with it, and it can also become severe and cause heart failure2.

Treatment either involves surgery to repair or replace the faulty valve, or a procedure such as a transcatheter aortic valve implantation (TAVI) to insert a new valve without removing the damaged one.

One way GPs can improve detection rates in their area is to auscultate – listen to the heart using a stethoscope – when patients present with symptoms typical of heart valve disease such as breathlessness and chest pain.

“Valve disease certainly needs to be on the list of conditions including hypertension and AF [atrial fibrillation] which GPs ‘automatically’ check for,” said Professor Chambers.

AF can also be a predictor – someone with current or previous AF is three times more likely to have some form of heart valve disease1.

Improving access to echo

Once GPs identify that a patient may have heart valve disease, the next step is to refer them for an echocardiogram, or ‘echo’, to confirm the diagnosis.

“The key to detection is to make echo more available,” said Professor Chambers.

However, GPs can struggle to access echocardiography services – something that Professor Chambers believes is holding up diagnosis for heart valve disease.

One reason is a lack of trained sonographers. Echocardiography training schemes have been overhauled in recent years, which has led to workforce shortages. “People are beginning to come into the system now, but the backlog is huge,” Professor Chambers said.

One solution to workforce issues could be a shorter ‘screening echo’ which would conduct a quick scan and determine whether patients had a problem that needed to be investigated further with a full echo. A recent study found that all patients who had valvular heart disease were picked up by a ‘screening echo’ as needing further investigation3.

Professor Chambers believes this kind of increased efficiency for echocardiographers could improve detection rates. “As technology improves, it’ll change the way echocardiographers work,” he said.

References

1. D'Arcy L, Coffey S, Loudon M et al (2016) Large-scale community echocardiographic screening reveals a major burden of undiagnosed valvular heart disease in older people: the OxVALVE Population Cohort Study. European Heart Journal. dx.doi.org/10.1093/eurheartj/ehw229

2. Nishimura RA, Otto CM, Bonow RO,  et al (2014) AHA/ACC guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol; 63:2438–88.  dx.doi.org/10.1016/j.jacc.2014.02.537

3. Draper J, Subbiah S, Bailey R et al (2018) Murmur clinic: validation of a new model for detecting heart valve disease. Heart. dx.doi.org/10.1136/heartjnl-2018-313393