Comparison of frequency of new coronary events in older persons with mild, moderate, and severe valvular aortic stenosis with those without aortic stenosis

Impact of concomitant aortic stenosis on the management and outcomes of acute myocardial infarction hospitalizations in the United States

Objective:

To evaluate the prevalence, management and outcomes of concomitant aortic stenosis (AS) in admissions with acute myocardial infarction (AMI).

Methods:

We used the HCUP-NIS database (2000–2017) to identify adult AMI admissions with concomitant AS. Outcomes of interest included prevalence of AS, in-hospital mortality, use of cardiac procedures, hospitalization costs, length of stay, and discharge disposition.

Results:

Among a total of 11,622,528 AMI admissions, 513,688 (4.4 %) were identified with concomitant AS. Adjusted temporal trends revealed an increase in STEMI and NSTEMI hospitalizations with concomitant AS. Compared to admissions without AS, those with AS were on average older, of female sex, had higher comorbidity, higher rates of NSTEMI (78.9 % vs 62.1 %), acute non-cardiac organ failure, and cardiogenic shock. Concomitant AS was associated with significantly lower use of coronary angiography (45.5 % vs 64.4 %), percutaneous coronary intervention (20.1 % vs 42.5 %), coronary atherectomy (1.7 % vs. 2.8 %) and mechanical circulatory support (3.5 % vs 4.8 %) (all p < 0.001). Admissions with AS had higher rates of coronary artery bypass surgery and surgical aortic valve replacement (5.9 % vs 0.1 %) compared to those without AS. Admissions with AMI and AS had higher in-hospital mortality (9.2 % vs. 6.0 %; adjusted OR 1.12 [95 % CI 1.10–1.13]; p <0.001). Concomitant AS was associated with longer hospital stay, more frequent palliative care consultations and less frequent discharges to home.

Conclusions:

In this 18-year study, an increase in prevalence of AS in AMI hospitalization was noted. Concomitant AS was associated with lower use of guideline-directed therapies and worse clinical outcomes among AMI admissions.

Lipoprotein(a) Gene Polymorphism Increases a Risk Factor for Aortic Valve Calcification

Calcific aortic valve disease (CAVD) is a multifactorial condition. Both environmental and genetic factors play an important role in its etiology. CAVD exhibits a broad spectrum, varying from mild valve thickening to severe valve calcification and stenosis. Progression of the disease consists of chronic inflammation, lipoprotein deposition, and active leaflet calcification. It is a process similar to coronary artery disease. In this study, we investigated Lp(a) levels and gene polymorphisms associated with calcific aortic stenosis from blood samples after echocardiography in the evaluation of 75 patients diagnosed with CAVD and 77 controls. Blood tests were run in our laboratory to rule out certain risk factors before echocardiography examination. A significant association among smoking, elevated LDL level and creatinine, low albumin levels, Lp(a) level, rs10455872, and rs3798220 polymorphisms may be considered genetic risk factors for the development of calcific aortic stenosis.

Cardiovascular morbidity and mortality in patients with aortic valve sclerosis: A systematic review and meta-analysis

AIMS

The association between aortic valve sclerosis (AVSc) and cardiovascular (CV) events is not consistent among different studies. We have performed a meta-analysis evaluating the association between AVSc and fatal and/or non-fatal CV and cerebrovascular events.

METHODS AND RESULTS

A systematic search was performed in the electronic databases (PubMed, Web of Science, Scopus, EMBASE). Studies evaluating coronary artery disease (CAD), stroke and CV mortality in AVSc patients and controls were included. Differences among cases and controls were expressed as Odds Ratio (OR) with pertinent 95% Confidence Intervals (CI). Thirty-one studies on 10,537 AVSc patients and 25,005 controls were included in the final analysis. The absolute risk of CAD was 45.8% (95% CI: 32.9-59.3) in AVSc patients and 29.4% (95% CI: 21.8-38.5) in controls with an OR of 2.02 (95% CI: 1.67-2.44) and an attributable risk of 35.8%. Moreover, stroke was reported in 11.8% (95% CI: 4.4-27.7) of AVSc patients and 7.9% (95% CI: 2.5-22.7) of controls (OR: 1.41, 95% CI: 1.16-1.71) with an attributable risk of 33.0%. CV mortality was 6.2% (95% CI: 2.7-13.5) in AVSc patients and 2.0% (95% CI: 0.5-7.9) in controls (OR: 2.70, 95% CI: 1.45-5.01), with an attributable risk of 67.7%. Results were confirmed when pooling together ORs for CAD, stroke and CV mortality obtained by means of multivariate analysis.

CONCLUSIONS

AVSc is associated with CAD, stroke and CV mortality. Taken together, these data suggest that patients with AVSc may benefit from a stricter CV risk monitoring and that AVSc screening may be included in the frame of CV risk stratification protocols.

Relation of left ventricular free wall rupture and/or aneurysm with acute myocardial infarction in patients with aortic stenosis

This minireview describes 6 previously reported patients with left ventricular free wall rupture and/or aneurysm complicating acute myocardial infarction (AMI) in patients with aortic stenosis. The findings suggest that left ventricular rupture and/or aneurysm is more frequent in patients with AMI associated with aortic stenosis than in patients with AMI unassociated with aortic stenosis, presumably because of retained elevation of the left ventricular peak systolic pressure after the appearance of the AMI.

The prevalence, incidence, progression, and risks of aortic valve sclerosis: a systematic review and meta-analysis

OBJECTIVES

The aim of this study was to comprehensively review the epidemiology of aortic sclerosis (ASc) and its association with cardiovascular events.

BACKGROUND

ASc, which is defined as thickening or calcification of the aortic valve without significant obstruction of blood flow, is a common finding on cardiac imaging.

METHODS

We searched MEDLINE and EMBASE from inception to April 2013 for studies describing the epidemiology of ASc and performed a meta-analysis of the risk of adverse events using a random effects model.

RESULTS

Twenty-two studies were identified from the systematic review. The prevalence of ASc increased in proportion to the average age of study participants, ranging from 9% in a study in which the mean age was 54 years to 42% in a study in which the mean age was 81 years. In total, 1.8% to 1.9% of participants with ASc had progression to clinical aortic stenosis per year. There was a 68% increased risk of coronary events in subjects with ASc (hazard ratio [HR]: 1.68; 95% confidence interval [CI]: 1.31 to 2.15), a 27% increased risk of stroke (HR: 1.27; 95% CI: 1.01 to 1.60), a 69% increased risk of cardiovascular mortality (HR: 1.69; 95% CI: 1.32 to 2.15), and a 36% increased risk of all-cause mortality (HR: 1.36; 95% CI: 1.17 to 1.59).

CONCLUSIONS

ASc is a common finding that is more prevalent with older age. Despite low rates of progression to ASc, there is an independent increase in morbidity and mortality associated with the condition.

A review of the pathophysiology, diagnosis, and treatment of aortic valve stenosis in elderly patients

Elderly patients experiencing valvular aortic stenosis (AS) show an increased prevalence of coronary risk factors, coronary artery disease, and other atherosclerotic vascular diseases. Angina pectoris, syncope or near syncope, and congestive heart failure are the 3 classic manifestations of severe AS in patients. Prolonged duration and late peaking of an aortic systolic ejection murmur best differentiate severe AS from mild AS upon physical examination of the patient. Doppler echocardiography is used to diagnose the severity of patient AS. In the article, indications for aortic valve replacement (AVR) in patients, the use of warfarin after AVR in patients with mechanical prostheses, and the use of aspirin or warfarin after AVR in patients with bioprosthesis are discussed. Transcatheter aortic valvular replacement should be performed in non-operable patients with symptomatic severe AS to improve their survival and quality of life rather than using regular medical management of the condition.

Patients with echocardiographic aortic valve calcium or mitral annular calcium have an increased prevalence of moderate or severe coronary artery calcium diagnosed by cardiac computed tomography

The association between aortic valve calcium (AVC) and mitral annular calcium (MAC), as diagnosed by two-dimensional echocardiography, was investigated in 138 patients (76 women and 62 men, mean age 64±8 years) seen in a private cardiology practice at the New York Medical College. Coronary artery calcium (CAC) scores were diagnosed by 64-multislice computed tomography. AVC was present in 25 of 57 patients (44%) with moderate or severe CAC (a CAC score of more than 100) and in 15 of 81 patients (19%) with no or mild CAC (a CAC score of 0 to 100), P<0.001. Moderate or severe AVC was present in nine of 57 patients (16%) with moderate or severe CAC, and in two of 81 patients (2%) with no or mild CAC, P<0.005. MAC was present in 18 of 57 patients (32%) with moderate or severe CAC, and in seven of 81 patients (9%) with no or mild CAC, P<0.001. Moderate or severe MAC was present in eight of 57 patients (14%) with moderate or severe CAC, and in two of 81 patients (2%) with no or mild CAC, P<0.001.

Therapeutic effect of statin on aortic stenosis: a review with meta-analysis

BACKGROUND

Aortic stenosis (AS) is a common progressive disease. Statins have been hypothesized to delay its progression via pleiotropic mechanisms. However, results of clinical trials focusing on statin therapy in AS patients have been controversial.

OBJECTIVE

To analyse and summarize the findings in recent statin trials and to discuss the rationale of statin usage in AS populations.

METHODS

A comprehensive database search was conducted by two independent reviewers. Controlled trials that compared progression of AS between statin and non-statin therapy published before 31 December 2008 were included. Data were extracted for meta-analysis, to estimate overall effects, if available. Factors that contributed to heterogeneities among the trials were analysed.

RESULTS

The meta-analysis included nine trials with a total of 2947 patients. Statin therapy displayed an overall statistically significant effect on delaying AS progression. The weighted mean difference (statin vs. control) of annual increase of peak aortic-jet velocity was -0·12 m/s (95% confidence interval -0·22 to -0·03); the increase of mean transaortic pressure gradient was -1·64 mmHg per year (-3·27 to -0·01); Heterogeneity-analysis suggested that the baseline risk factors and characteristics of the patients, the use of different statins, and the time point to initiate statin therapy, may be important considerations when interpreting the result of individual studies.

CONCLUSION

Although the Simvastatin and Ezetimibe in Aortic Stenosis (SEAS) trial reported negative results in delaying AS progression in low-risk patients, the potential benefits of statins in those with multiple risk factors and their value in preventing future coronary events call for further investigation of different categories of AS patients.

Aortic stenosis

Patients with aortic stenosis (AS) have an increased prevalence of coronary risk factors, coronary artery disease, and other atherosclerotic vascular disease and an increased incidence of coronary events and death. Statins may reduce the progression of AS. Angina pectoris, syncope or near syncope, and heart failure are the three classic manifestations of severe AS. Prolonged duration and late peaking of an aortic systolic ejection murmur best differentiate severe AS from mild AS on physical examination. Doppler echocardiography is used to diagnose the presence and severity of AS. Once symptoms develop, aortic valve replacement (AVR) should be performed in patients with severe or moderate AS. Warfarin should be administered indefinitely after AVR in patients with a mechanical aortic valve and in patients with a bioprosthetic aortic valve who have either atrial fibrillation, prior thromboembolism, left ventricular systolic dysfunction, or a hypercoagulable condition. Patients with a bioprosthetic aortic valve without any of these four risk factors should be treated with aspirin 75-100 mg daily.

Valvular Aortic Stenosis in the Elderly

Elderly patients with valvular aortic stenosis have an increased prevalence of coronary risk factors, of coronary artery disease, and evidence of other atherosclerotic vascular diseases. Statins may reduce the progression of aortic stenosis (AS). Angina pectoris, syncope or near syncope, and congestive heart failure are the 3 classic manifestations of severe AS. Prolonged duration and late peaking of an aortic systolic ejection murmur best differentiate severe AS from mild AS on physical examination. Doppler echocardiography is used to diagnose the prevalence and severity of AS. The indications for cardiac catheterization and the medical management of AS are discussed. Once symptoms develop, aortic valve replacement (AVR) should be performed in patients with severe or moderate AS. Other indications for AVR are discussed. Warfarin should be administered indefinitely after AVR in patients with a mechanical aortic valve and in patients with a bioprosthetic aortic valve who have either atrial fibrillation, prior thromboembolism, left ventricular systolic dysfunction, or a hypercoagulable condition. Patients with a bioprosthetic aortic valve without any of these 4 risk factors should be treated with aspirin 75-100 mg daily.

Heart disease and aging

CAD is the most common cause of death in older persons and was present in 43% of 1,160 men and in 41% of 2,464 women, mean age 81 years. Hypertension was present in 60% of these older women and in 57% of these older men. The prevalence of valvular aortic stenosis, aortic regurgitation, mitral regurgitation, and MAC increases with age in older men and in older women. The prevalence and incidence of CHF increase with age. CHF is the most common cause of hospitalization in persons aged 65 years and older. The prevalence of normal LV ejection fraction associated with CHF increases with age and is higher in older women than in older men. The prevalence of chronic atrial fibrillation increases with age and was present in 16% of 1,160 older men and in 13% of 2,464 older women. Atrial fibrillation is an independent predictor of new coronary events and thromboembolic stroke in older persons. Older persons who have unexplained syncope should have 24-hour ambulatory electrocardiograms to determine whether pauses of longer than 3 seconds are present that require permanent pacemaker implantation.

Increased prevalence of coronary artery disease, silent myocardial ischemia, complex ventricular arrhythmias, atrial fibrillation, left ventricular hypertrophy, mitral annular calcium, and aortic valve calcium in patients with chronic renal insufficiency

Cardiovascular morbidity and mortality is high in patients with chronic renal insufficiency. Patients with chronic renal insufficiency have an increased prevalence of coronary artery disease, silent myocardial ischemia, complex ventricular arrhythmias, atrial fibrillation, left ventricular hypertrophy, mitral annular calcium, and aortic valve calcium than patients with normal renal function. These risk factors for cardiovascular morbidity and mortality contribute to the increased incidence of cardiovascular morbidity and mortality seen in patients with chronic renal insufficiency.

Prevalence of valve calcium and association of valve calcium with coronary artery disease, atherosclerotic vascular disease, and all-cause mortality in 137 patients undergoing hemodialysis for chronic renal failure

Of 137 patients (mean age 63 years) who underwent hemodialysis for chronic renal failure, 65 (47%) had mitral valve calcium, mitral annular calcium, or aortic valve calcium. Thirty-eight of 65 patients (59%) who had valve calcium died at 3.5-year follow-up versus 21 of 72 patients (29%) who did not have valve calcium and who died at 4.3-year follow-up (p = 0.0005).

Aortic valve sclerosis as a marker of active atherosclerosis

Aortic sclerosis is a calcific disease of the aortic valvular leaflets defined as focal leaflet thickening without significant obstruction to left ventricular outflow. Several clinical factors are associated with calcific aortic valve disease, including male sex, smoking, hypertension, age, hypercholesterolemia, and diabetes. Histologic and biochemical studies suggest similarities between the mechanisms involved in the development of aortic sclerosis and atherosclerosis, suggesting these two diseases may share common pathophysiologic mechanisms. In a recent prospective trial, the presence of aortic sclerosis was associated with an approximately 50% increase in cardiovascular mortality and myocardial infarction, even after correction for age, gender, known coronary artery disease, and clinical factors associated with a aortic sclerosis.

Clinical predictors of prognosis in severe aortic stenosis in unoperated patients > or = 75 years of age

In elderly patients with severe aortic stenosis, clinical evaluation can dictate decision making. Asymptomatic patients in normal sinus rhythm, without left atrial enlargement and without bundle branch block, can be safely followed clinically, regardless of echocardiographic findings.

Association of mitral annular calcium and of aortic cuspal calcium with coronary artery disease in older patients

In a prospective study, mitral annular calcium (MAC) was present in 274 of 752 men (36%), mean age 80 years, and in 869 of 1,663 women (52%), mean age 82 years (p <0.0001); aortic cuspal calcium was present in 295 of 752 men (39%) and in 672 of 1,663 women (40%) without aortic cuspal calcium (p = NS). Coronary artery disease was present in 150 of 274 men (55%) with versus 192 of 478 men (40%) without MAC (p = 0.0001) and in 446 of 869 women (51%) with versus 276 of 794 women (35%) without MAC (p <0.0001); coronary artery disease was present in 167 of 295 men (57%) with versus 175 of 457 men (38%) without aortic cuspal calcium (p <0.0001), and in 360 of 672 women (54%) with versus 362 of 991 women (37%) without aortic cuspal calcium (p <0.0001).

The older man's heart and heart disease

CAD is the most common cause of death in older men and was present in 44% of 664 men, mean age 80 years. Independent risk factors for new coronary events in older men include increasing age, prior CAD, cigarette smoking, hypertension, diabetes mellitus, high serum total cholesterol, and low serum HDL cholesterol. In older men with hypertension, echocardiographic LVH is a powerful independent predictor of new coronary events, atherothrombotic brain infarction, and CHF. In 554 older men with a mean age of 80 years, two-dimensional and Doppler echocardiography demonstrated that the prevalence of aortic stenosis was 14%, 1 + aortic regurgitation or greater was 31%, rheumatic mitral stenosis was 0.4, 1 mitral regurgitation or greater was 32%, mitral annular calcium was 35%, hypertrophic cardiomyopathy was 3%, idiopathic dilated cardiomyopathy was 1%, left atrial enlargement was 29%, LVH was 41%, and abnormal LVEF was 29%. The prevalence and incidence of CHF increase with age in older persons. The prevalence of a normal LVEF associated with CHF as a result of prior myocardial infarction or hypertension was 22% in men aged 60 to 69 years, 33% in men aged 70 to 79 years, 41% in men aged 80 to 89 years, and 47% in men aged 90 years or older.

Comparison of frequency of new coronary events in older subjects with and without valvular aortic sclerosis

In a prospective study of 1,980 subjects (mean age 81 +/- 8 years) without valvular aortic stenosis, 981 (50%) had valvular aortic sclerosis diagnosed by 2-dimensional and continuous-wave Doppler echocardiography. Independent risk factors for new coronary events were prior coronary artery disease (p = 0.0001, risk ratio 2.8), male gender (p = 0.002, risk ratio 1.3), and valvular aortic sclerosis (p = 0.0001, risk ratio 1.8).