Despite the decline of rheumatic fever, valvular heart disease remains a common and important problem. The investigation and treatment of patients have been revolutionised by the widespread availability of echocardiography, which provides information about disease aetiology, accurate and non-invasive assessment of severity and a means of monitoring progression. These advances have facilitated progress in reconstructive valve surgery and the application of balloon valvuloplasty. Improved valve prostheses and reduction in peri-operative mortality have also broadened the indications for valve replacement surgery. A working party convened by the British Cardiac Society and the Royal College of Physicians of London have reviewed current practice and provided guidelines, summarised in this article, for the investigation and management of adults with valvular heart disease in primary care, district general hospitals and tertiary referral centres.