Cardiovascular Disease: Valvular Heart Disease

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Introduction 

Law enforcement officers (LEOs) with valvular heart disease may be capable of safe and effective job performance. However, clinical manifestations of valvular disease (e.g., syncopal episodes or symptoms of reduced cardiac output), could interfere with LEOs’ ability to perform essential job functions safely and effectively. Therefore, an individualized risk assessment is needed once a valvular heart condition is identified. The initial evaluation should include1: 

• A complete medical history including any symptoms of reduced cardiac output (e.g., shortness of breath, fatigue, pedal edema, decreased exercise tolerance, dyspnea on exertion, chest pain, dizziness, etc.), previous syncopal episodes, previous cardiac surgical procedures, medications, and results of previous cardiac tests. 
• Physical examination with particular importance of auscultation for systolic and diastolic murmurs. 
• Recent (within the past 12 months) electrocardiogram (ECG). 
• Recent (within the past 12 months) imaging (echo or nuclear) exercise stress test (EST) up to 12 METS. 
• Recent (within the past 12 months) transthoracic echocardiography. 

In 2020, the American College of Cardiology/American Heart Association (ACC/AHA) published an update to its guidelines for the management of patients with valvular heart disease.1 These guidelines included a grading process from Stage A (mild) to Stage D (severe) based on symptoms, valve anatomy, valve hemodynamics, and hemodynamic consequences (Tables 1-4 in the Appendix). Most individuals with mild to moderate (Stage A or B) valvular disease have no symptoms and the risk of sudden incapacitation is rare. However, individuals with severe valvular disease (Stage C or D) typically have symptoms, valve anatomy, or valve hemodynamics that prevent vigorous exercise and, in most circumstances, represent an indication for valve replacement.2 If there is discordance between the clinical symptoms, physical examination, and initial noninvasive testing, further noninvasive testing (computed tomography, cardiac magnetic resonance imaging) or invasive testing (transesophageal echocardiography, cardiac catheterization) may be indicated.1 

While ACC/AHA recommendations for the general population serve as a reference point for the evaluation of many cardiovascular conditions, LEOs must be held to a higher medical standard as first responders due, in part, to the increased physical job demands and the risk of public safety were they to become suddenly incapacitated.  

LEOs found to have heart murmurs suggestive of valvular heart disease should be evaluated with an echocardiogram even if the individual is asymptomatic or not known to have an abnormal cardiac valve.1 Based on expert opinion, Gerkin and Goldberg identified specific murmurs that may be suggestive of valvular heart disease which should be followed up with an echocardiogram. These murmurs include diastolic murmurs, ≥grade III systolic murmurs, grade II systolic murmurs that radiate to the neck or axilla, and systolic murmurs that increase on standing.3 

The remainder of this chapter provides fitness-for-duty criteria for: 

• Mitral Stenosis 
• Mitral Regurgitation 
• Mitral Valve Prolapse 
• Aortic Stenosis 
• Aortic Regurgitation 
• Valve (Mechanical or Bioprosthetic) Implants with Transcatheter or Surgical Approaches 

It may be helpful to specify murmur grades.  For example:  

1. faint, barely audible 
2. soft  
3. easily audible without a palpable thrill
4. easily audible with a palpable thrill
5. loud, audible with stethoscope lightly touching the chest
6. audible with stethoscope not touching the chest4