Specialist valve clinics: recommendations from the British Heart Valve Society working group on improving quality in the delivery of care for patients with heart valve disease

The population prevalence of moderate or severe valve disease in industrialised countries is as high as 13% in those aged 75 years or older.1 Undetected valve disease leads to premature death1 but valve surgery, when indicated, can prolong life.2 Access to medical care in industrialised countries is usually good, but limitations exist3 and better ways of organising care are needed.4 A working group was therefore convened by the British Heart Valve Society with representatives of all interested national bodies and a panel of invited international commentators. The aim was to produce recommendations to improve the detection, conservative management and interventional treatment of valve disease. This paper focusses on conservative management and proposes recommendations for overcoming limitations in care by means of a specialist valve clinic. The initial management of patients with valve disease is usually conservative and meticulous follow-up is then vital. However, accepted management guidelines are not followed adequately.5–7 Furthermore, the application of accepted guidelines requires specialist experience especially in determining whether a patient is genuinely asymptomatic. Most patients with valve disease are still cared for by general cardiologists or general physicians who may be less skilled than a valve disease specialist in making a diagnostic formulation. Furthermore, it is likely that advances in practice are more slowly assimilated by a generalist than by a cardiologist who undertakes specialist continuing education. As a result, patients are often referred for surgery too late. In the EuroHeart Survey,6 approximately one half of patients were in New York Heart Association class III or IV at the time of valve surgery. At least one third of elderly patients with severe aortic stenosis are not referred for surgery at all even when clinically indicated.8 Developing a percutaneous valve programme leads to increased rates of conventional surgery suggesting …