There are four valves in the heart. Valves are tissue structures that open and close to let blood in and out of the heart and direct blood flow in the heart.

When you have a disease of a valve, it either has a problem opening (stenosis) or closing, which causes blood to leak backward (regurgitation).

Let’s talk about how these conditions impact the four valves in the heart.

Mitral valve

This valve lets oxygenated blood into the pumping chamber of the heart. This valve can develop regurgitation or stenosis.

Mitral valve regurgitation can happen as a result of:

  • mitral valve prolapse (this is when the valve structure is floppy, so when the valve closes, it buckles backward and some blood leaks backward)
  • aging of the mitral valve
  • damage to the sub-valvular structures that control the opening and closing of the valve (this can happen during a heart attack in the back wall of the heart)
  • infection of the heart valve

Mitral valve stenosis usually occurs as a result of rheumatic heart disease, which is a strep infection that can damage the heart valve.

Aortic valve

This valve opens to lead blood out of the heart.

Aortic valve stenosis can occur as a result of:

  • aging of the valve
  • calcium deposits on the valve surface that prevent it from opening
  • a bicuspid aortic valve, a congenital condition in which an individual is born with two leaflets in the aortic valve instead of three (this causes problems with opening and closing of the valve, and it can also cause regurgitation)

Aortic valve regurgitation can also occur when the aorta, which is a tube that has the aortic valve at its base, becomes dilated or stretched, which can pull open the aortic valve leaflets, making them leaky.

Tricuspid and pulmonic valves

Conditions like carcinoid heart disease, in which chemicals cause damage to the heart valve, can affect these valves.

But they usually become regurgitant due to diseases that affect the function of the heart or due to high blood pressure in the lungs (pulmonary hypertension).

Acquired conditions of heart valve disease include degenerative conditions that cause heart valve disease (i.e., aging). Examples of these conditions are:

  • aortic valve stenosis
  • Barlow’s mitral valve disease
  • fibroelastic deficiency

Rheumatic heart disease is also a heart valve condition that can occur after a case of acute rheumatic fever.

Carcinoid valve disease can occur because of carcinoid tumors which secrete chemicals that can damage the heart valves (especially the right-sided heart valves: the tricuspid and pulmonic valves).

Endocarditis is a condition where there is a bloodstream infection that spreads to the heart. Bacterial growth can occur on valve surfaces, causing valvular dysfunction.

While heart valve disease isn’t usually considered an autoimmune condition, there are two particular autoimmune disorders that can be associated with heart valve lesions:

Systemic lupus erythematosus (SLE)

In SLE, valve disease can range from mitral valve prolapse, to valve growths consistent with nonbacterial thrombotic endocarditis. These growths are tissue attachments to the valve that can cause regurgitation or less commonly, stenosis.

Antiphospholipid antibody syndrome (APLA)

With APLA, valves can thicken or develop valve nodules similar to valvular growths. The mitral valve is more frequently involved, followed by the aortic valve, and regurgitation is more common than stenosis. The valve lesions, especially aortic nodules, are associated with a high risk of stroke.

People with an elevated level of lipoprotein (a), which is a risk marker, have a higher risk of having aortic stenosis.

Those who have mitral valve prolapse often also have a clinical condition of premature ventricular contractions (PVCs), which is a type of irregular heartbeat.

People who’ve had coronary artery disease with an inferior wall myocardial infarction (a heart attack that affects the back wall of the heart) have a higher risk of having mitral regurgitation.

Anyone who’s had endocarditis (a bloodstream infection that can affect the intracardiac structures) may develop regurgitant valve lesions.

Lung disease is associated with right-sided valvular lesions, such as tricuspid regurgitation.

Having hypertension and diabetes can mean having atrial dilation and a higher risk of atrial fibrillation, which is associated with mitral regurgitation.

This really depends on the type of valve disease.

Mitral valve prolapse is a condition that can often happen in young and otherwise healthy women and can run in families.

Aortic stenosis is usually a condition associated with aging, as well as diabetes, high blood pressure, high cholesterol, atrial fibrillation, and aging of the heart.

Atrial fibrillation is also often associated with mitral regurgitation. As the atria starts to enlarge and dilate, the mitral valve can become leakier. However, sometimes it’s difficult to know which came first, as the mitral regurgitation is what may have triggered atrial fibrillation in the first place.

Here are a few more common relationships:

  • Aortic regurgitation is associated with high blood pressure.
  • Tricuspid regurgitation is associated with chronic obstructive pulmonary disease (COPD) and pulmonary hypertension.
  • Mitral regurgitation is associated with atrial fibrillation, high blood pressure, and PVCs.

COPD is a lung disease that can cause changes in the way the lungs function and can also cause high blood pressure in the lungs (pulmonary hypertension).

This condition can put stress on the right side of the heart, which is the side of the heart that pumps deoxygenated blood to the lungs. The right-sided heart valves are the pulmonic and tricuspid valves, and when the pressure they are working against is high, they can become leaky.

The best way to manage valve disease is to manage the COPD so that the pressure in the lungs (pulmonary pressure) is low and the valves aren’t under stress.

If the COPD exists as a result of, or alongside, left-heart valve disease (such as mitral regurgitation), the valve leakiness back into the lungs can affect the function of the lungs, cause fluid in the lungs, and exacerbate symptoms.

In that case, managing blood pressure and, if necessary, taking diuretics to reduce pressure and leakiness in the heart can help with symptoms.

Diabetes can affect the heart valves by causing them to stiffen and thicken.

It also can affect the heart by causing stiffness of the heart muscle or blockages in the blood vessels around the heart that supply blood to the heart, which can lead to a condition called atherosclerosis.

If atherosclerosis results in extreme blockages to the heart muscle, you can develop congestive heart failure.

Diabetes is associated with aortic stenosis, and it may be more severe in people with diabetes than in people without diabetes.

Excess sugar in the blood is thought to be toxic to the heart valve cells, and the best way to control valve disease and other cardiac conditions in diabetes is to keep the sugar under control. A good goal for most people with diabetes is an HbA1c of less than 7 percent.

People with elevated cholesterol are at higher risk of developing blockages in the blood vessels around the heart, leading to lack of blood flow to the muscle. However, data shows that they may also be at increased risk for calcification and inflammation of the aortic valve.

This relationship is especially pronounced in people with elevated lipoprotein (a), or an extreme form of high cholesterol called familial hypercholesterolemia. These calcifications and valve changes can lead to aortic stenosis.

The best way to control the progression of this valve disease is to control the cholesterol. Ideally, the LDL-C should be less than 100 mg/dL for most people.

In those who are at higher risk or already have blockages or valve disease, the LDL-C goal should be shifted to less than 70 mg/dL.

It’s not clear whether treatment of elevated lipoprotein (a) can affect the progression of valve disease, but this is currently under investigation.

High blood pressure can cause heart valve disease in a number of ways. There are studies that suggest that elevated blood pressure can cause aortic valve disease.

This may be from high blood pressure causing microscopic injury to valve surfaces, causing thickening or calcium deposition and aortic stenosis.

The aorta, which carries blood out of the heart, can also get stretched, causing the aortic valve to be pulled open and become leaky (aortic regurgitation).

The best way to control valve disease in those who have high blood pressure is to control the blood pressure. The American College of Cardiology and American Heart Association guidelines recommend a blood pressure target of less than 130/80 in most patients.

It’s crucial that people with a heart valve disease and a comorbidity focus on managing the comorbidity.

Whether it’s high blood pressure, diabetes, high cholesterol, kidney disease, or a number of other comorbidities, treating the underlying condition is likely to prevent the progression of the valve disease.

In cases where the valve disease or heart disease is creating the comorbidity (for example, mitral regurgitation due to prolapse, which can create pulmonary hypertension), people should also consider medications, procedures, and surgeries to treat the valve disease itself.

In addition, making healthy lifestyle choices can help reduce the progression of heart valve disease. Steps may include exercising regularly, maintaining a moderate weight, limiting alcohol intake, not smoking, and treating other conditions, like sleep apnea.

Dr. Payal Kohli is an ABMS board certified noninvasive cardiologist specializing in advanced echocardiography, nuclear cardiology, and women’s heart disease. Dr. Kohli has also served as a section editor for Journal of the American College of Cardiology (JACC) and assistant editor for JACC Imaging.