Angina pectoris and coronary artery disease in severe aortic regurgitation

Accuracy of 64-slice computed tomography for the preoperative detection of coronary artery disease in patients with chronic aortic regurgitation

We studied the diagnostic accuracy of 64-slice computed tomography for the diagnosis of significant coronary artery disease (CAD) compared with conventional coronary angiography (CA) in patients with chronic aortic regurgitation (AR) referred for elective aortic valve surgery. Fifty consecutive patients with chronic AR (38 men, mean age 54 +/- 14 years) scheduled for valve surgery underwent 64-slice computed tomographic (CT) coronary angiography and CA. Significant stenosis was defined as a luminal diameter decrease >50%. Mean heart rate during CT scanning was 65.5 +/- 7.4 beats/min. Mean Agatston score was 136 +/- 278 (range 0 to 1207); prevalence of significant CAD in the study population was 26% (13 of 50 patients). Thirteen of 742 segments (1.8%) in 3 patients were considered nondiagnostic with computed tomography because of motion artifacts (n = 9) or calcium (n = 4). In a patient-based analysis taking nonevaluative segments as falsely positive, sensitivity, specificity, and positive and negative predictive values of computed tomography were 100%, 95%, 87%, and 100%, respectively. Preoperative CA could have been avoided in 70% of patients (35 of 50), CA would have been performed to confirm the CT diagnosis in 26% (13 of 50), and unnecessary CA would have been performed in 4% (2 of 50) on the basis of false-positive CT ratings. In conclusion, 64-slice CT coronary angiography provides high diagnostic accuracy for diagnosing significant CAD in patients with chronic AR and may be used as a filter test before valve surgery to decide whether CA should be performed.

Progress in mitral and aortic regurgitation

Over the past 15 years there has been rapid and dramatic change in the therapy for valvular heart disease. When mitral and aortic regurgitation are severe, they inevitably cause left ventricular damage, eventually resulting in death. However, when surgical correction of these lesions is timed appropriately, longevity can approach that of a normal population after surgery. As surgical techniques have improved, surgery is now indicated earlier in the course of these diseases. It is clear that some patients with mitral and aortic regurgitation require surgery even though they are entirely asymptomatic. However, it must be emphasized that mitral and aortic regurgitation are quite different from one another. These different lesions result in different loading conditions, different pathophysiologies, and have different means for surgical correction. All of these issues impact on the proper timing of surgery and are discussed.

Aortic regurgitation reduces the accuracy of exercise echocardiography for diagnosis of coronary artery disease

The association of aortic regurgitation with left ventricular size, hypertrophy, and abnormal coronary flow may influence the accuracy of stress testing techniques for the diagnosis of coronary disease. We examined the diagnostic accuracy of treadmill exercise echocardiography to predict coronary artery disease in 76 patients with moderate to severe aortic regurgitation. Rest and poststress images were interpreted by 2 experienced observers, and accuracy was defined by comparison with stenoses >/=50% diameter at coronary angiography. Results were compared with accuracy in a control group of previously published studies in patients without valvular heart disease. After 6 patients were excluded because of a submaximal heart rate response (<85% age-predicted maximal heart rate), 70 patients were included in the final analysis. Patients with aortic regurgitation were of comparable age to the control group and exercised to similar workload. In 16 (23%) patients with significant coronary artery disease and significant aortic regurgitation, the sensitivity of exercise echocardiography was 56% compared with 83% in the control group (P =.03). The specificity in 54 patients with aortic regurgitation but no significant coronary artery disease was 67% compared with 83% in the control group (P =.02). Accuracy was 64% in aortic regurgitation compared with 83% in the control group (P =.02). In patients with aortic regurgitation, accuracy in the left anterior descending artery territory (76%) marginally exceeded that in the posterior (right + circumflex coronary artery) circulation (70%). Thus the presence of significant aortic regurgitation affects the regional wall motion of the left ventricle during exercise and adversely affects the accuracy of exercise echocardiography for the diagnosis of coronary artery disease.

Frequency of angina pectoris and coronary artery disease in severe isolated valvular aortic stenosis

A consecutive series of 192 patients (121 men and 71 women, mean age 59 years, range 28 to 82) with isolated, severe valvular aortic stenosis was with isolated, severe valvular aortic stenosis was analyzed retrospectively to determine the relation of angina pectoris and coronary risk factors to angiographically significant coronary artery disease (CAD). Significant CAD (diameter reduction greater than or equal to 50%) was found in 47 patients (24%). Angina was present in 83% of them, but it was also found in 61% of the non-CAD patients. This symptom had as a result a low positive predictive value (31%). Of the patients without angina (n = 65) 12% had significant CAD. The negative predictive value of angina alone was thus 88%. By using multivariate logistic regression, a risk score could be calculated based on angina, age and sex, which increased the negative predictive value to 95%. It was concluded that coronary arteriography can only be omitted in severe aortic valvular stenosis, when patients have no angina and when they are less than 40 years of age for men and less than 50 years for women. For all other cases, coronary arteriography should be recommended.