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Acute Decompensated Aortic Stenosis: State of the Art Review. Curr Probl Cardiol 2022; 48:101422. [PMID: 36167225 DOI: 10.1016/j.cpcardiol.2022.101422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 09/21/2022] [Indexed: 11/21/2022]
Abstract
Aortic stenosis (AS) is a progressive disease that carries a poor prognosis. Patients are managed conservatively until satisfying an indication for transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement (SAVR) based on AS severity and the presence of symptoms or adverse impact on the myocardium. Up to 1 in 3 TAVIs are performed for patients with acute symptoms of dyspnoea at rest, angina, and/or syncope - termed acute decompensated aortic stenosis (ADAS) and require urgent aortic valve replacement. These patients have longer hospital length of stay, undergo physical deconditioning, have a higher rate of acute kidney injury and mortality compared to stable patients with less severe symptoms. There is an urgent need to prevent ADAS and to deliver pathways to manage and improve ADAS-related outcomes. We provide here a contemporary review on epidemiological and pathophysiological aspects of ADAS, with a focus on the impact of ADAS from clinical and economic perspectives. We will offer also a global overview of the available evidence for treatment of ADAS and with priorities suggested for addressing current gaps in the literature and unmet clinical needs to improve outcomes for AS patients.
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Maffeis C, Rossi A, Faggiano P. Aortic valve stenosis burden: Where we are now? Int J Cardiol 2021; 339:128-129. [PMID: 34293365 DOI: 10.1016/j.ijcard.2021.07.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 07/14/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Caterina Maffeis
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Andrea Rossi
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Pompilio Faggiano
- Cardiothoracic Department, Fondazione Poliambulanza, Brescia, Italy.
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Prevalence, clinical correlates, and burden of undiagnosed aortic stenosis in older patients: a prospective study in a non-cardiologic acute hospital ward. Aging Clin Exp Res 2020; 32:1533-1540. [PMID: 31970672 DOI: 10.1007/s40520-020-01471-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 01/03/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND The epidemiology of aortic stenosis (AS) in older patients admitted to non-cardiologic acute hospital wards and the effect of AS on mid-term survival are incompletely reported. In a cohort of very old patients admitted to an acute geriatric unit (AGU), we aimed to assess: (1) the prevalence of newly and previously diagnosed AS; and (2) the association between AS severity and patients' 6-month mortality. METHODS The patients consecutively admitted in two AGU rooms from February 2016 to February 2018 were assessed with echocardiography and AS severity was defined according to standard criteria. We assessed frailty using a 34-item Frailty Index (34-FI), which was operationalized using health variable information, and the Clinical Frailty Scale (CFS). Vital status at 6 months was extracted from Regional Register of Birth and Death. RESULTS Two hundred and three patients (mean age 84.5 ± 6.0 SD, female gender 56.1%) were included. Of these, 57 (28.1%) had AS, mild in 9 (4.5%), moderate in 32 (16.1%) and severe in 16 (8.1%). A new diagnosis of AS was obtained in 42 (73.7%) patients, of whom 33 (78.6%) had moderate or severe AS. At 6 months, 61 (28.9%) patients died. In multiple regression models, after adjusting for covariates, frailty, as assessed with both FI and CFS, was independent predictor of 6-month mortality whereas AS was not. CONCLUSIONS Among older patients admitted to non-cardiologic acute hospital wards, AS was common and frequently underdiagnosed. The severity of AS was not associated with increased 6-month mortality, whereas frailty was the most important predictor.
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Elmariah S, McCarthy C, Ibrahim N, Furman D, Mukai R, Magaret C, Rhyne R, Barnes G, van Kimmenade RRJ, Januzzi JL. Multiple biomarker panel to screen for severe aortic stenosis: results from the CASABLANCA study. Open Heart 2018; 5:e000916. [PMID: 30487984 PMCID: PMC6242008 DOI: 10.1136/openhrt-2018-000916] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Revised: 10/10/2018] [Accepted: 10/12/2018] [Indexed: 01/06/2023] Open
Abstract
Objective Severe aortic valve stenosis (AS) develops via insidious processes and can be challenging to correctly diagnose. We sought to develop a circulating biomarker panel to identify patients with severe AS. Methods We enrolled study participants undergoing coronary or peripheral angiography for a variety of cardiovascular diseases at a single academic medical centre. A panel of 109 proteins were measured in blood obtained at the time of the procedure. Statistical learning methods were used to identify biomarkers and clinical parameters that associate with severe AS. A diagnostic model incorporating clinical and biomarker results was developed and evaluated using Monte Carlo cross-validation. Results Of 1244 subjects (age 66.4±11.5 years, 28.7% female), 80 (6.4%) had severe AS (defined as aortic valve area (AVA) <1.0 cm2). A final model included age, N-terminal pro-B-type natriuretic peptide, von Willebrand factor and fetuin-A. The model had good discrimination for severe AS (OR=5.9, 95% CI 3.5 to 10.1, p<0.001) with an area under the curve of 0.76 insample and 0.74 with cross-validation. A diagnostic score was generated. Higher prevalence of severe AS was noted in those with higher scores, such that 1.6% of those with a score of 1 had severe AS compared with 15.3% with a score of 5 (p<0.001), and score values were inversely correlated with AVA (r=−0.35; p<0.001). At optimal model cut-off, we found 76% sensitivity, 65% specificity, 13% positive predictive value and 98% negative predictive value. Conclusions We describe a novel, multiple biomarker approach for diagnostic evaluation of severe AS. Trial registration number NCT00842868.
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Affiliation(s)
- Sammy Elmariah
- Cardiology Division, Department of Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA.,Baim Institute for Clinical Research, Boston, Massachusetts, USA
| | - Cian McCarthy
- Department of Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nasrien Ibrahim
- Department of Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Deborah Furman
- Cardiology Division, Department of Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Renata Mukai
- Cardiology Division, Department of Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | | | | | - Roland R J van Kimmenade
- Cardiology Division, Radboud University Medical Center, Maastricht, The Netherlands.,Cardiology Division, Maastricht University Medical Center, Maastricht, The Netherlands
| | - James L Januzzi
- Cardiology Division, Department of Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA.,Baim Institute for Clinical Research, Boston, Massachusetts, USA
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Argulian E, Windecker S, Messerli FH. Misconceptions and Facts About Aortic Stenosis. Am J Med 2017; 130:398-402. [PMID: 28109966 DOI: 10.1016/j.amjmed.2016.12.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Accepted: 12/12/2016] [Indexed: 11/28/2022]
Abstract
Aortic stenosis is the most common valvular heart disease leading to intervention, and it is typically a disease of the elderly. Recent clinical advances have expanded the role of transcatheter aortic valve intervention in patients with severe aortic stenosis, making aortic valve intervention feasible and effective even in patients at intermediate, high, and prohibitive surgical risk. With the rapid advances in treatment, proper diagnosis becomes crucial for a wide range of patients with aortic stenosis: from "concordant" high-gradient aortic stenosis to "discordant" low-gradient aortic stenosis. The latter group commonly presents a clinical challenge requiring thoughtful and comprehensive evaluation to determine eligibility for aortic valve intervention. Providers at all levels should be familiar with basic diagnostic caveats and misconceptions when evaluating patients with possible aortic stenosis.
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Affiliation(s)
- Edgar Argulian
- Mount Sinai Heart, Mt Sinai St. Luke's Hospital, New York, NY.
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Moore M, Chen J, Mallow PJ, Rizzo JA. The direct health-care burden of valvular heart disease: evidence from US national survey data. CLINICOECONOMICS AND OUTCOMES RESEARCH 2016; 8:613-627. [PMID: 27799803 PMCID: PMC5076539 DOI: 10.2147/ceor.s112691] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose This study quantified the overall effects of aortic valve disease (AVD) and mitral valve disease (MVD) by disease severity on direct health-care costs to insurers and patients. Materials and methods Based on 1996–2011 data from the Medical Expenditure Panel Survey (MEPS), a large, nationally representative US database, multivariate analyses were performed to assess the relationship between AVD and MVD and direct annual health-care costs to insurers and patients, at individual and US-aggregate levels. Adults aged 18 years and over with diagnosis codes for AVD or MVD based on International Classification of Diseases (ninth revision) diagnosis codes were identified. Subjects were further classified as symptomatic AVD, asymptomatic AVD, symptomatic MVD, and asymptomatic MVD. These classifications were determined with clinical assistance and based in part on data availability in the MEPS. Results The MEPS database included 148 patients with AVD: 53 patients with symptomatic AVD, 95 patients with asymptomatic AVD, and 1,051 with MVD, including 315 patients with symptomatic MVD and 736 patients with asymptomatic MVD. Symptomatic AVD had the largest incremental effect on annual per patient health-care expenditure: $12,789 for symptomatic AVD, $10,816 for asymptomatic AVD, $5,163 for symptomatic MVD, and $1,755 for asymptomatic MVD. When aggregated to the US population, heart-valve disease accounted for an incremental annual cost of $23.4 billion. The largest aggregate annual costs were incurred by patients with symptomatic MVD ($7.6 billion), followed by symptomatic AVD ($5.6 billion), asymptomatic MVD ($5.6 billion), and asymptomatic AVD ($4.6 billion). Conclusion The annualized incremental costs of heart-valve disease were substantial for all groups examined, and greatest for patients with symptomatic MVD. This reflects the relatively high prevalence associated with this group. With a growing and aging population, the prevalence of heart-valve disease is expected to rise, increasing the burden on public health.
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Affiliation(s)
- Matt Moore
- Global Health Economic Strategy, Edwards Lifesciences Inc, Irvine, CA
| | - Jie Chen
- Department of Health Services and Administration, University of Maryland, College Park, MD
| | - Peter J Mallow
- Health Economics and Outcomes Research, CTI Clinical Trial & Consulting Services Inc, Cincinnati, OH
| | - John A Rizzo
- Department of Preventive Medicine and Economics, Stony Brook University, Stony Brook, NY, USA
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Chiang SJ, Daimon M, Miyazaki S, Kawata T, Morimoto-Ichikawa R, Maruyama M, Ohmura H, Miyauchi K, Lee SL, Daida H. When and how aortic stenosis is first diagnosed: A single-center observational study. J Cardiol 2016; 68:324-8. [DOI: 10.1016/j.jjcc.2015.10.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Revised: 09/21/2015] [Accepted: 10/12/2015] [Indexed: 10/22/2022]
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Mureddu GF, Nistri S, Faggiano P, Fimiani B, Misuraca G, Maggi A, Gori AM, Uguccioni M, Tavazzi L, Zito GB. Evaluation of the appropriateness of the preclinical phase (stage A and stage B) of heart failure Management in Outpatient clinics in Italy rationale and design of the 'VASTISSIMO' study. J Cardiovasc Med (Hagerstown) 2016; 17:501-9. [PMID: 27028840 DOI: 10.2459/jcm.0000000000000332] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Early detection of heart failure, when still preclinical, is fundamental. Therefore, it is important to assess whether preclinical heart failure management by cardiologists is adequate. The VASTISSIMO study ('EValuation of the AppropriateneSs of The preclInical phase (Stage A and Stage B) of heart failure Management in Outpatient clinics in Italy') is a prospective nationwide study aimed to evaluate the appropriateness of diagnosis and management of preclinical heart failure (stages A and B) by cardiologists working in outpatient clinics in Italy. Secondary goals are to verify if an online educational course for cardiologists can improve management of preclinical heart failure, and evaluate how well cardiologists are aware of patients' adherence to medications. The study involves 80 outpatient cardiology clinics distributed throughout Italy, affiliated either to the Hospital Cardiologists Association or to the Regional Association of Outpatient Cardiologists, and is designed with two phases of consecutive outpatient enrolment each lasting 1 month. In phase 1, physicians' awareness of the risk of heart failure and their decision-making process are recorded. Subsequently, half of the cardiologists are randomized to undergo an online educational course aimed to improve preclinical heart failure management through implementation of guideline recommendations. At the end of the course, all cardiologists are evaluated (phase 2) to see whether changes in clinical management have occurred in those who underwent the educational program versus those who did not. Patients' adherence to prescribed medications will be assessed through the Morisky Self-report Questionnaire. This study should provide valuable information about cardiologists' awareness of preclinical heart failure and the appropriateness of clinical practice in outpatient cardiology clinics in Italy.
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Affiliation(s)
- Gian F Mureddu
- aAssociazioni Regionali Cardiologi Ambulatoriali (ARCA) bAssociazione Nazionale Medici Cardiologi Ospedalieri (Area Prevenzione ANMCO) cGVM Care & Research, Cotignola (RA), Italy
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Ludbrook G, Seglenieks R, Osborn S, Grant C. A call centre and extended checklist for pre-screening elective surgical patients – a pilot study. BMC Anesthesiol 2015; 15:77. [PMID: 25985775 PMCID: PMC4438626 DOI: 10.1186/s12871-015-0057-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 05/11/2015] [Indexed: 11/24/2022] Open
Abstract
Background Novel approaches to preoperative assessment and management before elective surgery are warranted to ensure that a sustainable high quality service is provided. The benefits of a call centre incorporating an extended preoperative electronic checklist and phone follow-up as an alternative to a clinic attendance were examined. Methods This was a pilot study of a new method of patient assessment in patients scheduled for elective non-cardiac surgery and who attended a conventional preoperative clinic. A call centre assessment, using a Computer-assisted Health Assessment by Telephone (CHAT), paper review by an anaesthetist, and a follow-up phone call if the anaesthetist wished more information, preceded the conventional preoperative clinic. Summaries from the call centre and clinic assessments were independently produced. The times spent by call centre staff were recorded. The ‘procedural anaesthetist’ (who provided anaesthesia for each patient’s actual surgery/procedure) documented an opinion on whether the call centre assessment alone would have been sufficient to bypass the preoperative clinic if the patient were hypothetically undergoing laparoscopic cholecystectomy. This opinion was also sought from a panel of four senior anaesthetists, based on patient summaries from both the call centre and preoperative clinic, but expanded to three hypothetical operations of different complexity – cataract removal, laparoscopic cholecystectomy, and total hip replacement. Results Call centre assessment followed by clinic attendance was studied in 193 patients. The mean time for CHAT was 19.8 (SD 7.5) minutes and, after review of CHAT summaries, anaesthetists telephoned 45.6 % of cases for follow-up information. The mean time spent by anaesthetists on summary review and phone calls was 3.8 (SD 3.9) minutes. Procedural anaesthetists considered 89 % of the patients under their care suitable to have bypassed the preoperative clinic if they were to have undergone cholecystectomy. The panel of senior anaesthetists judged 95-97 % of patients suitable to have bypassed preoperative clinic for cataract surgery, 81-85 % for cholecystectomy and 79-82 % for hip replacement. Conclusions A call centre to pre-screen elective surgical patients might substantially reduce patient numbers attending preoperative anaesthetic assessment clinics. Further studies to assess the quality of such an approach are indicated. Trial registration ANZCTRACTRN12614000199617.
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Affiliation(s)
- Guy Ludbrook
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, North Terrace, 5005, South Australia. .,Department of Anaesthesia, Royal Adelaide Hospital, Adelaide, North Terrace, 5000, South Australia.
| | - Richard Seglenieks
- Department of Anaesthesia, Royal Adelaide Hospital, Adelaide, North Terrace, 5000, South Australia.
| | - Shona Osborn
- Department of Anaesthesia, Royal Adelaide Hospital, Adelaide, North Terrace, 5000, South Australia.
| | - Cliff Grant
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, North Terrace, 5005, South Australia.
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