Valvular Disease
Recognize, monitor, and triage the common valve lesions — and know when symptomatic severe disease needs referral.
Learning Objectives
- 1.Recognize the common valve lesions by exam and echo.
- 2.Understand severity grading and surveillance at a high level.
- 3.Know when valve disease warrants referral or escalation.
Overview
Valve disease is common and often slowly progressive. The APP job is recognition, appropriate surveillance, symptom monitoring, and timely referral when disease becomes severe and symptomatic.
The common lesions
- •Aortic stenosis (AS): harsh systolic murmur, RUSB → carotids; exertional syncope/angina/dyspnea.
- •Aortic regurgitation (AR): diastolic decrescendo murmur; wide pulse pressure.
- •Mitral regurgitation (MR): holosystolic apex murmur → axilla.
- •Mitral stenosis (MS): diastolic rumble; associated AFib; rheumatic history.
Severity & surveillance
- •Echo grades severity (valve area, gradients, regurgitant severity, chamber/ventricular effects).
- •Surveillance echo intervals depend on lesion and severity; track symptoms and ventricular function.
- •Read the echo report and act on it (your scope) — not raw image interpretation.
When to refer / intervene
- •Severe symptomatic disease (e.g., severe symptomatic AS) → referral for intervention evaluation (AVR/TAVR; valve repair/replacement).
- •Declining ventricular function or specific echo thresholds may prompt intervention even before symptoms — cardiology-led.
- •New severe regurgitation or rapidly worsening symptoms → expedite.
Other management
- •Manage comorbidities (HTN, AFib, HF) per their guidelines.
- •Endocarditis prophylaxis only for specific high-risk patients/procedures (e.g., prosthetic valves) — not everyone.
- •Avoid vasodilator pitfalls in severe AS (preload/afterload sensitivity) — coordinate with physician.
Red flags / escalation
- •Exertional syncope with a harsh systolic murmur → severe AS concern.
- •Acute severe regurgitation (e.g., flash pulmonary edema, new murmur) → emergency.
- •Syncope, heart failure, or angina with known severe valve disease.
Escalate
Severe symptomatic valve disease — especially symptomatic severe AS or acute severe regurgitation — is urgent/emergent and physician/cardiology-led.
Common beginner mistakes
- •Treating symptomatic severe AS as routine follow-up.
- •Giving aggressive vasodilation/over-diuresis in severe AS without coordination.
- •Over-applying endocarditis prophylaxis.
- •Missing the link between MS/MR and AFib.
Nurse / MA workflow connection
- •Nurses triage syncope/dyspnea in valve patients; MAs flag new murmurs/symptoms and obtain vitals.
Mini cases
78-year-old with a harsh systolic murmur radiating to the carotids now has exertional syncope and an echo showing severe AS.
Action?
Show answer
Symptomatic severe aortic stenosis — refer promptly for intervention evaluation (AVR/TAVR) and involve the physician. This is not routine surveillance; symptomatic severe AS carries high risk.
Patient with a prosthetic valve scheduled for a dental procedure.
Prophylaxis?
Show answer
Prosthetic valves are a high-risk group for whom endocarditis prophylaxis before certain dental procedures is indicated — confirm per guideline. Most other patients do not need it.