Treatment Strategies in Symptomatic Intermediate, Low-Risk, and Asymptomatic Patients With Severe Aortic Stenosis

Silent coronary artery disease in asymptomatic patients with severe aortic stenosis and normal exercise testing

OBJECTIVE

There are no data about the prevalence of silent coronary artery disease in asymptomatic severe aortic stenosis patients with normal exercise testing. Importantly, unmasking significant coronary artery disease in patients with aortic stenosis could influence the choice/timing of treatment in these patients.

METHOD

Exercise testing was performed on semi-supine ergobicycle. Cardiopulmonary analysis during exercise testing, echocardiography, and laboratory analysis at rest was done. Standard clinical/electrocardiography criteria were assessed for symptoms/signs of ischemia during/after exercise testing. In patients with normal exercise testing coronary angiography was performed using standard femoral/radial percutaneous approach. Coronary stenosis was considered significant if >70% of vessel diameter or 50%-70% with fractional flow reserve ≤0.8.

RESULTS

Total of 96 patients with normal exercise testing were included (67.6 years, 50.6% males). No patient had any complication or adverse event. The Pmean was 52.7 mmHg, mean indexed aortic valve area was 0.36 cm/m and left ventricular ejection fraction, 69.5%. 19/96 patients (19.8%) had significant coronary artery disease on coronary angiography. Multivariate logistic regression analysis revealed brain natriuretic peptide and blood glucose as independent predictors of silent coronary artery disease. Brain natriuretic peptide value of 118 pg/ml had sensitivity/specificity of 63%/73% for predicting coronary artery disease (area under the curve 0.727, P = 0.006).

CONCLUSION

Our results are the first to show that in patients with severe aortic stenosis, normal left ventricular ejection fraction,, and normal exercise testing, significant coronary artery disease is present in as many as 1/5 patients. In such patients, further prospective studies are warranted to address the diagnostic value of brain natriuretic peptide in detecting silent coronary artery disease.

Pathophysiology, Diagnosis, and Treatment of Patients with Concomitant Severe Aortic Stenosis and Coronary Artery Disease: A Closer Look to the Unresolved Perplexity

Degenerative aortic stenosis (AS) and coronary artery disease (CAD) are the most prevalent cardiovascular diseases in developed countries, and they coexist in up to 50% of patients. The pathophysiological rationale behind concomitant AS and CAD is discussed in detail in this review, together with prognostic implications. Detecting CAD in patients with AS may be challenging, as AS may mask the existence and symptoms of CAD. The safety and reliability of invasive and non-invasive physiological assessment for epicardial coronary disease are also a matter of debate. Finally, the selection and timing of optimal treatment of CAD in patients with severe AS are still unclear. Given the aging of the population, the increase in the prevalence of AS, and the ongoing paradigm shift in its treatment, controversies in the diagnosis and treatment of CAD in the setting of AS are deemed to grow in importance. In this paper, we present contemporary issues in the diagnosis and management of CAD in patients with severe AS who are transcatheter aortic valve implantation (TAVI) candidates and provide perspective on the treatment approach.

Aortic Stenosis in African Americans: Focus On Disparities in Treatment and Outcomes

Aortic stenosis (AS) is the third most common type of cardiovascular disease after hypertension and coronary artery disease, and it carries a high mortality rate when left untreated. Risk factors include male sex, hypertension, tobacco use, advanced age, elevated LDL cholesterol, and coronary atherosclerosis. Definitive treatment for AS includes valve repair, either percutaneously or surgically; however, in aging populations corrective surgery carries increased risk. While research suggests that patients of some non-White ethnic groups, including African-Americans, are less likely than their Caucasian counterparts to have AS, these minority patients may experience may experience differences in the way they receive and accept care. This paper seeks to explicate the mechanisms of racial disparities among the African-Americans affected by aortic stenosis as they pertain to healthcare utilization, referral for valve replacement, acceptance of therapy, and overall treatment outcomes.