Skip to main content

Main menu

  • HOME
  • ONLINE FIRST
  • CURRENT ISSUE
  • ALL ISSUES
  • AUTHORS & REVIEWERS
  • SUBSCRIBE
  • BJGP LIFE
  • MORE
    • About BJGP
    • Conference
    • Advertising
    • eLetters
    • Alerts
    • Video
    • Audio
    • Librarian information
    • Resilience
    • COVID-19 Clinical Solutions
  • RCGP
    • BJGP for RCGP members
    • BJGP Open
    • RCGP eLearning
    • InnovAIT Journal
    • Jobs and careers

User menu

  • Subscriptions
  • Alerts
  • Log in

Search

  • Advanced search
British Journal of General Practice
Intended for Healthcare Professionals
  • RCGP
    • BJGP for RCGP members
    • BJGP Open
    • RCGP eLearning
    • InnovAIT Journal
    • Jobs and careers
  • Subscriptions
  • Alerts
  • Log in
  • Follow bjgp on Twitter
  • Visit bjgp on Facebook
  • Blog
  • Listen to BJGP podcast
  • Subscribe BJGP on YouTube
Intended for Healthcare Professionals
British Journal of General Practice

Advanced Search

  • HOME
  • ONLINE FIRST
  • CURRENT ISSUE
  • ALL ISSUES
  • AUTHORS & REVIEWERS
  • SUBSCRIBE
  • BJGP LIFE
  • MORE
    • About BJGP
    • Conference
    • Advertising
    • eLetters
    • Alerts
    • Video
    • Audio
    • Librarian information
    • Resilience
    • COVID-19 Clinical Solutions
Debate & Analysis

Detecting heart valve disease: can we do better?

Jane Draper and John Chambers
British Journal of General Practice 2016; 66 (644): 156-157. DOI: https://doi.org/10.3399/bjgp16X684181
Jane Draper
Cardiac Physiologist, Department of Adult Echocardiography, Cardiothoracic Centre, St Thomas’ Hospital, London.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
John Chambers
Consultant Cardiologist, Department of Adult Echocardiography, Cardiothoracic Centre, St Thomas’ Hospital, London.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Data
  • Info
  • eLetters
  • PDF
Loading

BACKGROUND

It is not widely known that valve disease is as common as heart failure, with a prevalence of 2.5% in the general population and over 10% in those aged >75.1 There are many well-established national programmes for heart failure yet none exist for valve disease, which can justifiably be regarded as the ‘next cardiac epidemic waiting to happen’.2

There are many limitations in our care for heart valve disease. Most patients are still cared for by general physicians or GPs without specialist expertise despite management decisions becoming increasingly complex.3 One-half of patients throughout Europe receive surgery too late.4 The situation is particularly poor for older people, at least 30% of whom are not referred even when clinically indicated.3 There is unacceptable variation in access to aortic valve surgery in the UK,5 particularly in London where Camden has observed activity 47% above age-predicted rates and Brent has activity 40% below age-predicted rates.

These limitations have led to a call for specialist valve clinics.3,6 These are expected to improve the assessment of valve disease and the timing of surgery, and to ensure referral to an appropriately qualified and experienced surgeon or interventional cardiologist. However, unless valve disease is detected more frequently in the community these improvements in secondary or tertiary care will be ineffective.

BARRIERS TO DETECTION IN THE COMMUNITY

Murmurs are a clue to the diagnosis but are unreliable because they may be physiological or may disappear in severe valve disease as heart failure develops. Furthermore, GPs in the UK are less likely than their colleagues in France to auscultate either routinely or if the patient reports a potential cardiac symptom.7 About one-half of echocardiograms indicated for murmur are normal,7 but the yield of valve disease is increased by about 50% by extending the indications for echocardiography beyond murmur alone (Box 1).

Box 1.

Indications for echocardiography to detect valve disease

  • Pathological murmur

  • Exertional breathlessness or chest pain

  • COPD with disproportionate breathlessness

  • Atrial fibrillation

  • First-degree relative with bicuspid aortic valve

  • Originating from a country with a high prevalence of rheumatic disease

  • Age >75 years

Echocardiography is the key to detection but it remains a relatively scarce resource. A study takes 45 minutes and usually involves a visit to the hospital. The uptake of open-access echocardiography varies between practices, by a factor of over 150 in one audit.8 GPs recognise that interpretation of open-access reports is difficult,9 meaning that, unless strong systems are in place, the diagnosis of valve disease may not be ‘flagged’ and an appropriate referral to specialist clinics may be missed.

HOW CAN CARDIAC ULTRASOUND BE DELIVERED BETTER IN THE COMMUNITY?

The challenge is both to deliver echocardiography to more patients and to focus studies on those most likely to have valve disease. It has been suggested10 that a brief point-of-care scan can be used to pre-screen the need for a more extensive transthoracic study. These scans take about 10 minutes and can be performed using a hand-held device allowing near-patient testing anywhere in the community. They are best regarded as an extension of the clinical examination and are increasingly used in the acute setting11 to aid immediate management and to triage the urgency with which a full scan is required.

We have recently developed a model with a point-of-care scan and auscultation as screening steps (Figure 1) to identify patients referred for open-access echocardiography having a high likelihood of heart valve disease. Auscultation ensures that uncommon pathologies associated with murmurs such as coarctation and muscular ventricular septal defects are not missed, because these would not be detected by a point-of-care scan. In a pilot of 75 patients, no patient with a normal point-of-care scan and normal auscultation subsequently had an abnormal transthoracic echocardiogram (TTE). But who should run such a clinic? Sonographers’ career structure is now expanding and clinical examination skills including auscultation are within the syllabus of the new consultant clinical scientist role currently being developed by the Department of Health. A screening service such as is suggested here is consistent with the extended clinical role expected of this discipline. This means that, in the future, cardiologists will be freed to concentrate on creating management plans for patients in whom valve disease has been identified in scientist-led diagnostic clinics.

Figure

Proposed clinic structure using point-of -care scans in the evaluation of patients with suspected heart valve disease. TTE = transthoracic echocardiogram.

Models for delivering echocardiography including point-of-care and full transthoracic studies will vary according to local resources although some basic standards are essential (Box 2). A sonographer-led clinic, at its most simple, is an open-access service incorporating a clinical response framed within a protocol agreed by cardiologists and GPs. The sonographer can direct normal scans back to the GP for reassurance, those with moderate or severe disease can be referred directly to a specialist valve clinic, and those with mild disease requiring follow-up can be seen every 3–5 years as indicated by guidelines. This type of clinic could be conducted in the community either in larger practices or multispecialty community providers.12

Box 2.

Standards required of a community echo service

  • Run by sonographer with appropriate qualification and experience (currently at least level 7 in the future consultant clinical scientists)

  • Report and interpretation provided

  • Quality control

  • Expert back-up for opinion on echo

  • Ability to refer patients with significant structural disease to specialist valve and heart failure clinics

  • Convenient (based at the surgery or geographically close with good public transport links)

  • Availability is maximised

CONCLUSION

Valve disease is much more common than appreciated and often undetected. Standard echocardiography is expensive, has a low yield of abnormalities, and is not widely available. We suggest that clinical scientist-led diagnostic clinics including screening with auscultation and point-of-care scans will allow better focusing of transthoracic echocardiography and will improve the management of patients with heart valve disease. These clinics could be based at large community centres with strong links to specialist services based at the nearest hospital.

Notes

Provenance

Freely submitted; externally peer reviewed.

Competing interests

The authors have declared no competing interests.

  • © British Journal of General Practice 2016

REFERENCES

  1. 1.↵
    1. Nkomo VT,
    2. Gardin JM,
    3. Skelton TN,
    4. et al.
    (2006) Burden of valvular heart diseases: a population–based study. Lancet 368(9540):1005–1011.
    OpenUrlCrossRefPubMed
  2. 2.↵
    1. d’Arcy JL,
    2. Prendergast BD,
    3. Chambers JB,
    4. et al.
    (2011) Valvular heart disease: the next cardiac epidemic. Heart 97(2):91–93.
    OpenUrlFREE Full Text
  3. 3.↵
    1. Chambers J,
    2. Ray S,
    3. Prendergast B,
    4. et al.
    (2013) 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. Heart 99(23):1714–1716.
    OpenUrlFREE Full Text
  4. 4.↵
    1. Lung B,
    2. Baron G,
    3. Butchart EG,
    4. et al.
    (2003) A prospective survey of patients with valvular heart disease in Europe: the Euro Heart Survey on valvular heart disease. Eur Heart J 24(13):1231–1243.
    OpenUrlCrossRefPubMed
  5. 5.↵
    1. Bridgewater B,
    2. Keogh B,
    3. Kinsman R,
    4. Walton P
    (2009) Demonstrating quality: sixth National Adult Cardiac Surgery database report (Dendrite Clinical Systems Ltd, Henley-on-Thames).
  6. 6.↵
    1. Lancellotti P,
    2. Rosenhek R,
    3. Pibarot P,
    4. et al.
    (2013) Heart valve clinics: organisation, structure, and experiences. Eur Heart J 34(21):1597–1606.
    OpenUrlCrossRefPubMed
  7. 7.↵
    1. Webb J,
    2. Thoenes M,
    3. Chambers J
    (2014) Identifying heart valve disease in primary care: differences between practice in Germany, France and the United Kingdom. Eur J Cardiovasc Med doi:10.5083/ejcm.20424884.124.
    OpenUrlCrossRef
  8. 8.↵
    1. Chambers J,
    2. Kabir S,
    3. Cajeat E
    (2014) Detection of heart disease by open access echocardiography: a retrospective analysis of general practice referrals. Br J Gen Pract doi:10.3399/bjgp14X677167.
    OpenUrlAbstract/FREE Full Text
  9. 9.↵
    1. Fuat A,
    2. Hungin PS,
    3. Murphy JJ
    (2003) Barriers to accurate diagnosis and effective management of heart failure in primary care: qualitative study. BMJ 326(7382):196–201.
    OpenUrlAbstract/FREE Full Text
  10. 10.↵
    1. Arden C,
    2. Chambers JB,
    3. Sandoe J,
    4. et al.
    (2014) Can we improve the detection of heart valve disease? Heart 100(4):271–273.
    OpenUrlFREE Full Text
  11. 11.↵
    1. Hothi SS,
    2. Sprigings D,
    3. Chambers J
    (2014) Point-of-care cardiac ultrasound in acute medicine: the quick scan. Clin Med 14(6):608–611.
    OpenUrlAbstract/FREE Full Text
  12. 12.↵
    1. NHS England
    (2014) Five year forward view, http://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf (accessed 29 Jan 2016).
Back to top
Previous ArticleNext Article

In this issue

British Journal of General Practice: 66 (644)
British Journal of General Practice
Vol. 66, Issue 644
March 2016
  • Table of Contents
  • Index by author
Download PDF
Download PowerPoint
Email Article

Thank you for recommending British Journal of General Practice.

NOTE: We only request your email address so that the person to whom you are recommending the page knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Detecting heart valve disease: can we do better?
(Your Name) has forwarded a page to you from British Journal of General Practice
(Your Name) thought you would like to see this page from British Journal of General Practice.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
Detecting heart valve disease: can we do better?
Jane Draper, John Chambers
British Journal of General Practice 2016; 66 (644): 156-157. DOI: 10.3399/bjgp16X684181

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero

Share
Detecting heart valve disease: can we do better?
Jane Draper, John Chambers
British Journal of General Practice 2016; 66 (644): 156-157. DOI: 10.3399/bjgp16X684181
del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One
  • Mendeley logo Mendeley

Jump to section

  • Top
  • Article
    • BACKGROUND
    • BARRIERS TO DETECTION IN THE COMMUNITY
    • HOW CAN CARDIAC ULTRASOUND BE DELIVERED BETTER IN THE COMMUNITY?
    • CONCLUSION
    • Notes
    • REFERENCES
  • Figures & Data
  • Info
  • eLetters
  • PDF

More in this TOC Section

  • SAFER diagnosis: a teaching system to help reduce diagnostic errors in primary care
  • An Australian reflects on the Collings report 70 years on
  • Emergencies in general practice: could checklists support teams in stressful situations?
Show more Debate & Analysis

Related Articles

Cited By...

Intended for Healthcare Professionals

BJGP Life

BJGP Open

 

Tweets by @BJGPjournal

 
 

British Journal of General Practice

NAVIGATE

  • Home
  • Current Issue
  • All Issues
  • Online First
  • Authors & reviewers

RCGP

  • BJGP for RCGP members
  • BJGP Open
  • RCGP eLearning
  • InnovAiT Journal
  • Jobs and careers

MY ACCOUNT

  • RCGP members' login
  • Subscriber login
  • Activate subscription
  • Terms and conditions

NEWS AND UPDATES

  • About BJGP
  • Alerts
  • RSS feeds
  • Facebook
  • Twitter

AUTHORS & REVIEWERS

  • Submit an article
  • Writing for BJGP: research
  • Writing for BJGP: other sections
  • BJGP editorial process & policies
  • BJGP ethical guidelines
  • Peer review for BJGP

CUSTOMER SERVICES

  • Advertising
  • Contact subscription agent
  • Copyright
  • Librarian information

CONTRIBUTE

  • BJGP Life
  • eLetters
  • Feedback

CONTACT US

BJGP Journal Office
RCGP
30 Euston Square
London NW1 2FB
Tel: +44 (0)20 3188 7400
Email: journal@rcgp.org.uk

British Journal of General Practice is an editorially-independent publication of the Royal College of General Practitioners
© 2023 British Journal of General Practice

Print ISSN: 0960-1643
Online ISSN: 1478-5242