Valvular heart disease is becoming more prevalent as the United States’ population ages, with aortic and mitral valves most commonly affected. Complications, including syncope, heart failure, dyspnea, and chest pain, can arise from slow progression of stenosis and regurgitation, though acute regurgitation from an ischemic or traumatic event can be life-threatening. Patients with valvular disease may present with cardiogenic shock, and vasoactive agent treatment will depend on determination of the valvular etiology. This issue reviews aortic and mitral valvular disease as potential causes of a patient’s emergency department presentation, including history, diagnostic testing, and physical examination findings that can help guide treatment.
How would you manage these patients? Subscribe for evidence-based best practices and to discover the outcomes.
1. “This patient has frequent COPD exacerbations.” Do not fail to include valvular pathology in the differential diagnosis. Patients can have diverse pathology, which can present similarly to their chronic conditions. Therefore, it is important to avoid prematurely anchoring on a diagnosis.
5. “The inpatient service can treat the atrial fibrillation.” It is important to manage the patient’s vital signs and symptoms, especially during an acute event, to optimize cardiac functioning. Nonetheless, in certain valve diseases, abnormal vital signs are a compensatory mechanism and should not be treated. Atrial fibrillation should be treated.
6. “The patient crashed when we intubated him.” Anesthesia can acutely worsen a cardiac event due to the vasodilation that is associated with anesthetics. Any use of anesthetics should be carefully considered for timing and preparedness. Pressors and any adjunctive therapies should be prepared prior to using anesthetics.
Subscribe to access the complete Risk Management Pitfalls to guide your clinical decision making.
Subscribe for full access to all Tables and Figures.
Buy this issue and
Following are the most informative references cited in this paper, as determined by the authors.
7. * Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021;143(5):e72-e227. (Clinical guidelines) DOI: 10.1161/CIR.0000000000000932
11. NASEMSO Medical Directors Council. National model EMS clinical guidelines. 2019. Accessed July 15, 2021. (Guidelines)
23. * Maheshwari V, Barr B, Srivastava M. Acute valvular heart disease. Cardiol Clin. 2018;36:115-127. (Review) DOI: 10.1016/j.ccl.2017.08.006
27. * Akodad M, Schurtz G, Adda J, et al. Management of valvulopathies with acute severe heart failure and cardiogenic shock. Arch Cardiovasc Dis. 2019;112:773-780. (Review) DOI: 10.1016/j.acvd.2019.06.009
31. * van Diepen S, Katz JN, Albert NM, et al. Contemporary management of cardiogenic shock: a scientific statement from the American Heart Association. Circulation. 2017;136(16):e232-e268. (AHA Scientific Statement) DOI: 10.1016/j.ccc.2014.03.001
Subscribe to get the full list of 49 references and see how the authors distilled all of the evidence into a concise, clinically relevant, practical resource.
Keywords: aortic, mitral, stenosis, regurgitation, valvular, rheumatic, prolapse, endocarditis, shock, transthoracic, echocardiography, transesophageal, edema, vasoactive, prosthetic
Adam Sigal, MD; Stephanie Costa, MD
Abbas Husain, MD; Evan Leibner, MD
August 1, 2022
August 1, 2025   CME Information
4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAFP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits.
Price: $59
+4 Credits!