Cardiovascular — Sub-theme 3: Valvular Heart Disease (VHD)

Sub-theme leads: Dr Saul Myerson and Dr Bernard Prendergast

Valvular heart disease (VHD) is increasingly common, though poorly researched. International guidelines and current practice are based on out-dated studies and consensus opinion – there are virtually no randomised controlled trials. The VHD sub-theme is working to address the following important questions with direct applicability to NHS patients:

Identifying the prevalence of VHD:

OxVALVE study – this is the first community based study worldwide, which follows a group of people over time, to have defined the prevalence (occurrence) of VHD in over 2500 patients. Comparisons with smaller national and international groups of people will yield insight into genetic/ethnic variation, and underlying risk factors (including socioeconomic deprivation).

Identifying which patients are at risk:

  • Follow up of OxVALVE patients will define rates of disease progression, risk markers for prognosis, and whether mild VHD is of clinical concern.
  • Cardiac magnetic resonance (CMR) has already improved our ability to predict progression of asymptomatic patients to surgery. We plan a trial to determine if patients can avoid unnecessarily early surgery and whether early surgery provides true clinical benefit.
  • Studies to improve image quality using 3D echocardiography and image fusion techniques will lead to improved identification of valve structure and function.
  • We are following up groups of patients with bicuspid aortic valves (and their families) using novel CMR techniques.

Limiting disease progression

  • We have completed a detailed physiological study of the effects of the ACE inhibitor, ramipril, on the heart muscle in 100 patients with disease of the heart valves in which the opening of the aortic valve is narrowed (aortic stenosis).
  • We are planning similar studies to evaluate further specific targets for medical treatment of aortic stenosis
  • Innovative imaging techniques allow assessment of valve structure and heart muscle thickening.

Our work involves interaction with several other BRC or NIHR programmes both in Oxford [Bioengineering (image fusion, flow modelling), Imaging (technical CMR flow development), Cohorts (nested within OxVALVE), Oxford Radcliffe Biobank (OxVALVE), and OXVASC] and also nationally [National BRC/BRU links: OxVALVE epidemiological comparisons (Manchester, Leicester), collaborative SALTIRE II study (Edinburgh), atorvastatin/fibrosis (Birmingham)].

Relevance of research to the health of patients and the public: This research addresses key questions that impact directly on patient care and NHS resources. By identifying suitable patients for early valve surgery we aim to improve outcomes while removing the need for unnecessary follow up in others. The introduction of echocardiographic screening into primary care we hope will achieve early detection of not only VHD but other key cardiac conditions (e.g. latent congestive cardiac failure).

Understanding contemporary epidemiology in the UK will inform healthcare planning and define the practicality and need for echocardiographic screening. New biochemical and imaging markers of disease progression will allow patient selection for early intervention.

Involvement of patients and the public:

  • OxVALVE engages directly with the public through general practice surgeries and the study website (www.oxvalve.nhs.uk) which includes extensive information for patients.
  • The RIAS trial (www.rias.orh.nhs.uk) and OxBAV project (www.cardiov.ox.ac.uk/oxbav) provide enhanced information to the public and potential study subjects.
  • OxVALVE subjects have assisted with the Health Talk Online project assessing public experience of participation in research studies.