Valvular heart disease is damage to one or more heart valves. A stenotic valve does not open fully, so the chamber behind it must pump harder against resistance (pressure overload). A regurgitant (insufficient) valve does not close fully, so blood leaks backward (volume overload). The mitral and aortic valves are affected most often.

Causes: rheumatic heart disease (especially mitral stenosis, common in low- and middle-income countries), age-related calcification (aortic stenosis in older adults), congenital bicuspid aortic valve, infective endocarditis, myocardial infarction (papillary muscle dysfunction causing mitral regurgitation), and connective tissue disorders.

Cardiomyopathy is disease of the heart muscle itself.

DCM causes include ischemia, alcohol, cocaine, some chemotherapy (anthracyclines), myocarditis, pregnancy (peripartum cardiomyopathy), and genetic variants.

Murmur recognition

General findings: fatigue, exertional dyspnea, orthopnea, palpitations, edema, JVD, crackles, chest pain, dizziness or syncope, reduced activity tolerance.

Valve disease

• Heart failure symptoms: diuretics, sodium restriction; GDMT when EF is reduced (see Heart Failure topic)
• Mitral stenosis: beta blockers or nondihydropyridine calcium channel blockers slow the heart rate and lengthen diastole, improving left ventricular filling — they are helpful, not contraindicated. Anticoagulation with warfarin if AF, prior embolism, or left atrial thrombus (DOACs are not used in moderate–severe rheumatic MS). Percutaneous balloon mitral commissurotomy for suitable valves; surgery otherwise
• Aortic stenosis: no drug relieves the obstruction. Valve replacement — surgical (SAVR) or transcatheter (TAVR) — once severe AS causes symptoms (or earlier in selected asymptomatic clients, e.g., LVEF below 50%). Use vasodilators (nitrates) and diuretics cautiously; these clients depend on adequate preload
• Regurgitant lesions: afterload reduction and BP control; surgical repair or replacement (transcatheter edge-to-edge repair for selected MR)
• MVP: reassurance; beta blocker for troublesome palpitations

Prosthetic valves

Endocarditis prophylaxis (current AHA guidance): antibiotics before dental procedures that manipulate gums or perforate oral mucosa only for high-risk clients — prosthetic valve or prosthetic material used for repair, previous infective endocarditis, certain congenital heart disease, and cardiac transplant with valvulopathy. Native valve disease alone (including AS and MVP) does not require prophylaxis. Good oral hygiene and regular dental care matter for everyone. Typical regimen: amoxicillin 2 g orally 30–60 minutes before the procedure; with penicillin allergy, azithromycin or clarithromycin 500 mg, or doxycycline 100 mg (clindamycin is no longer recommended).

Cardiomyopathy

• DCM: HFrEF therapy (ARNI/ACE inhibitor/ARB, beta blocker, MRA, SGLT2 inhibitor), diuretics; goal is to improve pumping (contractility) and prevent remodeling. ICD or CRT when criteria are met; transplant or ventricular assist device for advanced disease. Abstain from alcohol
• HCM: beta blockers or verapamil/diltiazem to slow the heart rate and improve filling (use verapamil/diltiazem cautiously with severe outflow obstruction and low BP). Mavacamten (cardiac myosin inhibitor) for symptomatic obstructive HCM — available through a restricted (REMS) program with regular echocardiograms because it can lower EF and cause HF; contraindicated with certain CYP2C19/CYP3A4 inhibitors and inducers; may cause fetal harm, so effective contraception is required (it can reduce the effect of combined hormonal contraceptives). Septal myectomy or alcohol septal ablation for refractory obstruction; ICD for high sudden-death risk
• HCM — avoid drugs that worsen outflow obstruction: positive inotropes such as digoxin, pure vasodilators (nitrates, dihydropyridine calcium channel blockers), and aggressive diuresis or dehydration. Hypotension in obstructive HCM is treated with fluids and phenylephrine, not inotropes
• Restrictive: treat the cause (e.g., tafamidis for transthyretin amyloidosis); careful diuresis

Drug safety reminders: beta blockers (bradycardia, hypotension, do not stop abruptly), verapamil (hypotension, constipation, avoid in HFrEF), warfarin (INR, bleeding, pregnancy contraindication), diuretics (hypokalemia, volume depletion).

Listed in priority order.

1. Airway, breathing, circulation — for pulmonary congestion: high-Fowler's position, oxygen to target SpO₂, prepare IV diuretic
2. Syncope in aortic stenosis — treat as serious: it signals critically limited cardiac output and risk of dysrhythmia and sudden death. Place on continuous ECG monitoring, ensure safety, report immediately
3. Monitor rhythm — new AF in MS or MR raises embolic risk; watch for neurologic changes
4. Fluid balance — daily weight, intake and output; avoid dehydration in AS and HCM
5. Anticoagulation safety — INR, bleeding precautions, fall prevention
6. Activity — pace activities, rest periods; stop and report chest pain, dyspnea, or dizziness
7. After valve surgery or TAVR — monitor for bleeding, tamponade, conduction block (a pacemaker may be needed after TAVR), stroke, and access-site complications

• Report increasing dyspnea, fatigue, fainting, chest pain, palpitations, or rapid weight gain
• HCM: avoid dehydration, hot tubs/saunas, and heavy alcohol; avoid intense, strenuous exertion unless cleared by an HCM specialist — mild-to-moderate recreational activity is generally encouraged under current guidance. First-degree relatives need screening
• MVP: most people need no restrictions; limit caffeine and other stimulants if palpitations bother you; follow-up echocardiograms as advised
• Mechanical valve: lifelong warfarin, INR tests, consistent vitamin K intake, medical alert identification; plan pregnancy with the cardiologist
• Tell every dentist and provider about your valve; practice good dental hygiene; ask whether you need antibiotics before dental work (only high-risk conditions)
• Report fever, chills, or new fatigue (possible endocarditis)
• DCM: follow HF self-care (daily weight, sodium limit, medications); avoid alcohol and cocaine

• Stenosis = valve won't open; regurgitation = valve won't close
• MS → diastolic rumble at apex, AF, embolism, PND; most often rheumatic
• MR → holosystolic murmur at apex radiating to axilla
• AS → systolic murmur at right 2nd ICS to carotids; angina, syncope, HF; syncope = high sudden-death risk
• AR → diastolic murmur, wide pulse pressure, bounding pulse
• Beta blockers help in MS (longer filling time)
• HCM → avoid digoxin, nitrates, dehydration; beta blocker or verapamil; sudden death in athletes
• DCM → systolic failure; goal is better contractility and HF therapy
• Mechanical valve → lifelong warfarin; DOACs contraindicated
• Endocarditis prophylaxis only for high-risk clients (prosthetic valve, prior IE)