Beyond AS
For the many Americans living with valvular diseases, dizziness, fatigue, shortness of breath and abnormal
heart rhythms are a few of the many symptoms that they live with daily. This debilitating condition not only affects their hearts, it also impacts many other aspects of their lives. Despite available treatment options, far too many people still die from complications related to delaying or forgoing treatment.
Diseases of the heart valves become more prevalent with increasing age. According to a study published in Lancet, less than 1% of the U.S. population between the ages of 18 and 44 has heart valve disease. This increases
to 8.5% between ages 65 and 74 and climbs to 13.2% after age 75. Published studies estimate that approximately 5 million people in the U.S. are living with heart valve disease — although that number could now be as high as 8.7 to 11.6 million, according to the Alliance for Aging Research.
The aortic valve, which governs blood flow from the left ventricle to the aorta, is one of the culprits of patient death from valvular diseases. In fact, the Centers for Disease Control & Prevention estimates this valve is responsible for 61% of all deaths from valvular heart disease.
Aortic stenosis, a narrowing of the aortic valve opening, is one of the
most common and serious valve dis-ease problems and thus gets warranted attention. But increasing attention is also being paid to diseases in the heart’s other valves, including the mitral and tricuspid valves, which respectively account for over 15% and 24% of valvular heart disease deaths. In addition to their significant impact on people’s health and quality of life, the increasing number of treatments and minimally invasive options are creating new conversations around these cardiac conditions.
Aging Population Means More Valve Disease
As the population ages, physicians are seeing more mitral and tricuspid valve disease, notes Firas Zahr, M.D., an assistant professor of cardiovascular medicine in the OHSU School of Medicine and co-director of the OHSU Knight Cardiovascular Institute’s Complex Heart Valve Program. While age increases the incidence of valvular diseases, it also prohibited surgical treatment in years past, when physicians didn’t think their patients would survive.
“Many older or frail patients are not good candidates for open-heart surgery,” Dr. Zahr says. “But today, many of those same patients can now go home the day after having a minimally invasive transcatheter heart valve procedure.”
The opportunity for treatment outside of invasive surgical procedures allows for treatment of a much broader patient population, he says.
Devices continue getting smaller and more delicate, and the minimally invasive approach used to place them, studies show, is associated with less pain, smaller incisions, shorter hospital stays and recovery times and much less overall wear and tear on the body compared to traditional open-heart surgery. Using a percutaneous incision, a catheter is placed in an artery accessible via the patient’s groin to deploy a repair device or complete valve replacement through a small incision. The approach also requires less anesthesia than open-heart surgery and alleviates the need for a heart/lung bypass machine, says Dr. Zahr, who emphasizes how rare it is to find a patient who can’t be helped by one of today’s many new treatment options.
“As the therapy is becoming less invasive, people who are not candidates for traditional options are coming to us for minimally invasive transcatheter options.”
Heart-to-Heart Conversations
It’s critical that primary care physicians listen to their patients to establish a diagnosis. Murmurs, or an abnormal noise from the heart, can indicate that the valve has narrowed or has regurgitation (where some blood is flowing backward through a valve). This prevents the heart from efficiently pumping blood to the body. Primary care physicians (PCPs) may order an echocardiogram after hearing a murmur or noticing other symptoms, which are easy to remember with the acronym “LISTEN”:
Lightheaded, faint or dizzy feelings
Irregular heartbeat, heart flutter or chest pains
Shortness of breath after light activity or while lying down
Tiredness, even if they’ve had plenty of sleep
Edema
Not feeling like themselves or missing out on daily activities
“A lot of diseases go unrecognized for a long period of time, but it’s because a lot of them are not thought to be as severe as they actually are,” says Dr. Zahr, who notes that because many symptoms are driven by exercise, they are not as evident when the patient is at rest.
Many PCPs are unaware of the rapidly growing number of therapies available — treatments that, today, make people candidates for valvular replacement or repair when they might not have been before.
“[At OHSU], we have six or seven clinical trials that make valve repair
available for patients. The difficulty is actually trying to figure out which one of those options is the best,” Dr. Zahr says. He explains that a large, multidisciplinary team at OHSU reviews every case together in a weekly review board meeting to get many different perspectives on which repair might be best for the patient.
It’s also important for PCPs treating patients with mitral or tricuspid valve disease to work with them on healthy habits, like eating well, limiting salt intake, getting proper activity and learning to listen carefully to their bodies. Dr. Zahr also recommends referring
the patient to a center of excellence in valvular repair and replacement; centers with good outcomes tend to have a wider variety of treatments and clinical trial options available for patients.
“While there is a lot of great information out there written by different societies about time for intervention for disease like mitral and tricuspid regurgitation, most of us who handle these patients really enjoy conversations directly with PCPs,” Dr. Zahr says.
“I wish more PCPs knew that treatment for mitral or tricuspid valve disease is not what it was even two or three years ago. The field is evolving rapidly, and we have many more options for patients.”
