GPAtlas🧭 When to suspect
Suspect valvular heart disease in any adult with:
• A newly noted heart murmur.
• Otherwise unexplained exertional breathlessness, angina, palpitations, dizziness or syncope – particularly exertional syncope.
The everyday primary-care task is a simple one: decide who needs an echocardiogram, who needs it urgently, and who can be reassured.
Valve disease is overwhelmingly a disease of older age.
• Community echocardiographic screening (the UK OxVALVE study) found a valve abnormality in about half of people over 65, but the great majority is mild.
• Of those over 65, roughly 1 in 9 have moderate or severe disease, and this rises steeply with each decade.
• In the UK the dominant cause is now age-related calcific degeneration, not rheumatic disease.
• Symptoms may arise from the valve lesion itself or from secondary atrial fibrillation or heart failure.
Recognising the four common lesions by their murmur is the core skill:
| Lesion | Classic murmur | Key associated pointer |
|---|---|---|
| Aortic stenosis | Ejection systolic, loudest at the aortic area, radiates to the carotids | Soft or absent second heart sound, slow-rising pulse, narrow pulse pressure |
| Mitral regurgitation | Pansystolic at the apex, radiates to the axilla | • Soft first heart sound • Often coexists with atrial fibrillation |
| Aortic regurgitation | Early diastolic at the left sternal edge (patient sitting forward, in expiration) | Collapsing (water-hammer) pulse, wide pulse pressure |
| Mitral stenosis | Mid-diastolic rumble at the apex (left lateral position, bell) | • Loud first heart sound, opening snap • Usually rheumatic • Atrial fibrillation common |
Source: NICE NG208
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