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Recent advances in transcatheter procedures and improved outcomes after valve surgery mean that intervention can (and should) be considered in all patients\u00a0\u2013\u00a0even the elderly and those with multiple comorbidities \u2010 at earlier stages of the natural history of primary VHD, before the onset of irreversible left ventricular dysfunction (and frequently before the onset of symptoms). All patients with known VHD should be monitored carefully in the setting of a heart valve clinic and those who meet guideline criteria for surgical or transcatheter intervention referred for intervention without delay.<\/jats:p>\n                  <jats:p>High quality evidence for the use of medical therapy in VHD is limited and achieving target doses in an elderly and comorbid population frequently challenging. Furthermore, determining whether the valve or ventricle is the principal disease driver is crucial (although the distinction is not always binary, and often unclear). Guideline\u2010directed medical therapy remains the mainstay of treatment for secondary mitral regurgitation \u2010 although up to 50% of patients may fail to respond and should be considered for cardiac resynchronization, transcatheter or surgical valve intervention. Early and definitive management strategies are essential and should be overseen by a specialist Heart Team that includes a Heart Failure specialist. In this article, we provide an evidence\u2010based summary of approaches to the medical treatment of VHD and clinical guidance for the best management of patients in situations where high quality evidence is lacking.<\/jats:p>","DOI":"10.1002\/ejhf.2097","type":"journal-article","created":{"date-parts":[[2021,1,14]],"date-time":"2021-01-14T19:45:19Z","timestamp":1610653519000},"page":"1325-1333","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":18,"title":["The advantages, pitfalls and limitations of guideline\u2010directed medical therapy in patients with valvular heart disease"],"prefix":"10.1093","volume":"23","author":[{"given":"Harminder","family":"Gill","sequence":"first","affiliation":[{"name":"School of Bioengineering and Imaging Sciences King's College London  London UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Omar","family":"Chehab","sequence":"additional","affiliation":[{"name":"Cardiovascular 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