As many as half of the patients older than 65 years have valvular heart disease (VHD), often without obvious symptoms. While there is no effective medical therapy, early intervention can improve outcomes for patients with severe VHD.

But how, exactly, should early detection happen?

There are no simple answers. There’s a lack of data, clinical guidance, and physician agreement about early screening in this population. The cost of screening, and the potential for patient anxiety and overdiagnosis, further cloud things. Yet the question will only become more pressing as the US population older than 65 years is booming at a historic rate.

“Valvular heart disease increases substantially with age and is often clinically silent until patients have advanced disease or irreversible cardiac damage,” said Mario Goessl, MD, director of transcatheter valve therapies at the Center for Valve and Structural Heart Disease of the Minneapolis Heart Institute, Minneapolis, Minnesota.

There are no practice standards for how physicians should proceed when patients present with these questions. Neither the 2020 ACA/AHA nor the 2025 ESC/EACTS valvular heart disease guidelines endorse screening asymptomatic adults, though both address evaluation of known or suspected disease.

Auscultation Misses Many Cases

However, there are no practice standards for how physicians should proceed when patients present with these questions. Neither the 2020 ACA/AHA nor the 2025 ESC/EACTS valvular heart disease guidelines endorse screening asymptomatic adults, though both address evaluation of known or suspected disease. Detection in practice is typically “opportunistic,” such as detecting a murmur during routine examinations, said Colombus Batiste, MD, an interventional cardiologist and co-founder of the nonprofit organization Healthy Heart Nation.

However, Batiste noted, in asymptomatic primary care patients older than 65 years, auscultation detects only 32% of mild and 44% of significant VHD. Cardiologists fare little better. In the Seventh Tromsø Study (2015-2016), involving 2082 participants aged ≥ 40 years (mean age, 64 years), just 35.5% of patients with significant VHD had an audible murmur.

Citing the OxVALVE study, in which researchers screened 2500 patients for undiagnosed VHD via transthoracic echocardiography, Batiste suggested screening programs should focus on the older end of the spectrum.

In that study, VHD rose from 42.4% at ages 65-69 to 76.3% at 85-95, and moderate-to-severe disease from 3.3% at ages 65-74 to 11.9% at 75 years or older, Batiste said, adding that handheld and point-of-care ultrasound need to be studied for increased accurate “stethoscope extenders.”

Transthoracic Echocardiography

Goessl recommends screening for VHD beginning at age 65 by transthoracic echocardiography.

In the 2023 Heart of New Ulm Valve Study, Goessl and collaborators prospectively screened adults aged 65 years or older without diagnosed valve disease. They found 16% had previously undiagnosed moderate or severe valve disease and that 35% had at least mild valve disease.

“Importantly, 77% of participants with valve disease had minimal or no symptoms, underscoring that symptom-based detection alone will miss many patients,” he said. “For that reason, I would not limit screening only to symptomatic patients.”

Goessl noted that a careful clinical exam including auscultation for murmurs and assessment of symptoms or atrial fibrillation remains important.

“In health systems where resources are limited, a focused or abbreviated echocardiographic screening protocol — or point-of-care ultrasound performed by trained personnel — may be a reasonable first step, with comprehensive echocardiography reserved for patients with abnormal screening findings,” he said.

Screening Is Not Always Benign

“I don’t feel that we are at a stage where we know that universal screening for heart valve disease among older people should be recommended,” said Nicholas Jones, MD, a cardiologist at Oxford University Hospitals and an investigator in the OxVALVE study.

“If people have symptoms suggestive of heart valve disease such as breathlessness, angina, or syncope, then they should definitely have appropriate testing to investigate the cause of those, but that is obviously quite different to screening all adults of a certain age who do not have symptoms,” Jones said.

Jones and collaborators from Oxford and St Thomas’ Hospital in London, England, screened over 4000 patients older than 65 years for VHD in the OxVALVE study. In 2021, they reported results showing the prevalence and severity of VHD were closely linked with advancing age, and that mild VHD was very common but not associated with increased mortality, nor did it cause symptoms. Clinically significant VHD was also not associated with an increased risk for death in adjusted models. Among all participants, 70.2% had some form of valve abnormality.

One potential risk of widespread screening for VHD that Jones highlighted is anxiety among patients regarding a finding, such as mild regurgitant valve disease, that may not be significant for that individual’s current health or future outlook.

“Most people in OxVALVE were found to have relatively mild regurgitant valve disease, most often of the mitral or tricuspid valves,” Jones said. “Less than 5% of people in OxVALVE have aortic stenosis, although patients with established aortic stenosis at baseline were excluded, so this may be an under-estimate of the true population prevalence.”

Model for Mobile Screening?

A mobile heart screening initiative at the Ottawa Heart Institute serves as a potential model for population-level VHD screening.

Led by David Messika-Zeitoun, MD, a cardiologist and director of the Centre for Valvular Heart Disease at the Ottawa Heart Institute, Ottawa, Ontario, Canada, the program offers cardiovascular disease (CVD) screening for all adults older than 18 years with no known CVD, and heart valve screening for people 65 years or older. Screening is available on site at the Ottawa Heart Institute or at various community locations throughout the Ottawa region.

In 2025, researchers published results of a study conducted through the mobile heart screening program showing a 7% rate of VHD in participants. Messika-Zeitoun said that number is lower than some similar studies because participants have no known history of heart disease.

The program targets underserved communities, including people who don’t have a regular doctor, who have low socioeconomic status, or belong to a racial or ethnic group that faces increased CVD risk, Messika-Zeitoun said.

“We try to reach the population that are less likely to get screening,” Messika-Zeitoun said. “Early intervention [in valvular disease] is always more beneficial than late intervention. If you wait for symptoms, the outcome is significantly worse.”

Although the mobile screening program has been effective, Messika-Zeitoun said in its current form it is not necessarily scalable.

“The limitation of point-of-care echocardiography is that you need someone with some expertise,” Messika-Zeitoun said. He hopes that eventually AI can bring a type of screening to more patients by aiding in both image acquisition and interpretation. “It’s like video games,” he said. “AI can tell you if you get a good view or how to improve the view.”

Adding Up the Costs

Cost is also a factor when developing a screening program for large populations. Messika-Zeitoun said his group hopes to present results of a cost-effectiveness analysis for mobile CVD screening at an upcoming medical meeting and is working on a cost-effectiveness analysis for VHD screening. Ideally, he said, the program should save money for the healthcare system overall.

A 2024 analysis in ECC-QCCO showed echocardiogram screening for aortic stenosis at age 80 had an incremental cost-effectiveness of CA$28,005 (US$20,435), suggesting it would be cost-effective when the health system is willing to pay at or below a threshold of CA$50,000 per quality-adjusted life year.

The analysis was based on the BELFRAIL study of the very older in Belgium. Nearly half of the patients in the study, whose average age was 84 years, had aortic stenosis, leading to uncertainty whether its conclusions are generalizable to other populations.

“Probably screening is a good thing, but we need more data for people who are younger,” said Pouya Motazedian, MD, a cardiologist at the University of Ottawa Heart Institute and one of the authors of the ECC-QCCO health economics analysis. While acknowledging the caveats around potential harms for population screening programs.

Echocardiographic screening for valvular disease meets principles laid out by the World Health Organization for beneficial use, Motazedian noted. He also said echocardiography is a superior mode of screening for VHD compared with mass screening programs for other conditions like cervical cancer, which rely on surrogate markers for disease.

“Compared to those other screening programs, echocardiogram is a diagnostic test,” Motazedian said. “You’re not screening, you’re actually diagnosing, so your rate of false positives and false negatives is much lower.”

Messika-Zeitoun reported being funded by a research grant from Edwards Life Sciences. Jones, Batiste, and Motazedian reported having no relevant financial disclosures.

Catherine Shaffer is a freelance science and medical writer with a background in molecular biology and pharmaceutical research. Her work has appeared extensively in scientific trade and mainstream publications and on public radio.