Heart failure is usually the end point with progression of most valvular lesions, leading to stages B, C, and D heart failure usually preceded by long latent asymptomatic periods. With progression, most valve lesions lead to volume or pressure overload, leading to symptoms of heart failure: fatigue, shortness of breath, early satiety, symptoms and signs related to systemic venous hypertension. Given increased life expectancy across the world, more so in the West, advanced valvular lesion as a cause for symptomatic heart failure has increased, with a significant increase in prevalence beyond the age of 75 years. 1 Nkomo V.T. Gardin J.M. Skelton T.N. et al. Burden of valvular heart diseases: a population-based study.

Lancet. 2006; 368: 1005-1011

In a landmark paper from a combination of large epidemiologic studies in the general population from the United States that included comprehensive echocardiographic evaluation of valvular function, moderate or severe valve disease was thought to be present in nearly one in eight subjects (13.3%) aged 75 years and older, with a male predominance. Mitral regurgitation (MR) was the most common lesion followed by aortic stenosis (AS), with most of these subjects having echocardiographic findings of pressure or volume overload, which independently contributed to subsequent mortality. 1 Nkomo V.T. Gardin J.M. Skelton T.N. et al. Burden of valvular heart diseases: a population-based study.

Lancet. 2006; 368: 1005-1011

, 2 Writing Committee M. Otto C.M. Nishimura R.A. et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.

J Am Coll Cardiol. 2021; 77: 450-500

, 3 Supino P.G. Borer J.S. Preibisz J. et al. The epidemiology of valvular heart disease: a growing public health problem.

Heart Fail Clin. 2006; 2: 379-393

, 4 Vahanian A. Beyersdorf F. Praz F. et al. 2021 ESC/EACTS guidelines for the management of valvular heart disease.

Eur Heart J. 2022; 43: 561-632

This further highlighted the underdiagnosis of severe valve disease in the community and the integral role of quantitative echocardiography in this population. In addition, significant burden of atrial fibrillation in this age group has been independently shown to increase the long-term risk for significant mitral and tricuspid regurgitation, 5 Deferm S. Dauw J. Vandervoort P.M. et al. Atrial functional mitral and tricuspid regurgitation.

Curr Treat Options Cardio Med. 2020; 22: 30

suggesting the need for closer follow-up in this subgroup of elderly patients. There is also increased recognition of delayed diagnosis and treatment among women 6 Kislitsina O.N. Zareba K.M. Bonow R.O. et al. Is mitral valve disease treated differently in men and women?.

Eur J Prev Cardiol. 2019; 26: 1433-1443

and other ethnic minorities with recent literature highlighting potential ways to overcome these gaps in care. 7 Racial and ethnic disparities in heart failure: current state and future directions.

Curr Opin Cardiol. 2021; 36: 320-328