GPAtlas🧭 When to suspect
Suspect valvular heart disease in any adult with a newly noted heart murmur, or with 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; moderate or severe disease affects roughly 1 in 9 of those over 65 and 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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