guidelines

heart valve disease presenting in adults

nice ng208 practical guide: which murmurs need echocardiography, when to refer urgently (e.g., exertional syncope), and specialist referral after echo results.

last reviewed: 2026-02-13
based on: NICE NG208 (published 17 Nov 2021; last reviewed 24 Oct 2025; update in progress for TAVI topics)
reviewer: Dr Kola Tytler MBBS CertHE MBA MRCGP
view official NICE source

Primary care triage of murmurs (NICE)

Consider an echocardiogram for an adult with a murmur and no other signs/symptoms if valve disease is suspected based on murmur nature, family history, age (especially >75), or medical history (e.g. AF).

Offer an echocardiogram to adults with a murmur (and suspected valve disease) if they have symptoms/signs (e.g. breathlessness, angina, oedema) or an abnormal ECG, or if there is an ejection systolic murmur with a reduced second heart sound even without symptoms.

Urgent referral criteria (the “don’t miss” set)

  • Urgent (within 2 weeks) specialist assessment including echo (or urgent echo if specialist assessment unavailable) for adults with systolic murmur + exertional syncope.
  • Consider urgent (within 2 weeks) specialist assessment for adults with a murmur and severe symptoms (angina or breathlessness on minimal exertion or at rest) thought to be valvular.

After echo: who should see cardiology

  • Mild valve disease is common and rarely progresses rapidly; many patients can be monitored in primary care with a clear re-referral trigger set.
  • Refer to specialist if echo shows moderate or severe valve disease of any type.
  • Refer all bicuspid aortic valves (even mild) due to lifetime risk and associated aortopathy considerations.

Frequently asked questions

Does every murmur need an echo?
No. NICE frames echo use around suspected valve disease based on murmur character plus age/history/ECG/symptoms. Innocent murmurs in low-risk contexts do not automatically require echocardiography.
What is the single “high-risk murmur presentation” to remember?
Systolic murmur with exertional syncope — urgent specialist assessment (within 2 weeks) is recommended.
Can mild disease be monitored outside cardiology?
Often yes, provided there is a clear monitoring interval (local protocol) and explicit re-referral triggers (new symptoms, murmur change, abnormal ECG, heart failure signs).

Transparency

This page is an educational, clinician-written summary of publicly available NICE guidance intended for trained healthcare professionals. It uses original wording (not copied text) and should be used alongside the full NICE source, local pathways, and clinical judgement. Doses provided are for general reference; always check the BNF/SPC.