Abstract The physiological importance of valvular heart disease relates to its effects on cardiopulmonary performance. Symptom onset equates with a distinct change in natural history. The development of atrial fibrillation (AF), ventricular remodeling, hypertrophy, and/or pump dysfunction impacts long-term survival. Diagnosis is most commonly triggered by the appreciation of a heart murmur, following which a decision is made regarding the need for echocardiography for further assessment. Many heart murmurs are benign and need not prompt additional testing. Institution of medical therapy to ameliorate symptoms or prevent complications, such as the use of vitamin K antagonists for patients, should be coupled with an appraisal of the indications for surgical or percutaneous intervention. An integrated understanding of natural history based on the severity of the valve lesion within the context of individual patient comorbidities is the foundation for appropriate clinical decision making. We review here the major valve lesions; treatment and prevention of infective endocarditis are covered elsewhere.