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

Impact of pretransplant mitral annular calcification on the incidence of cardiac events after renal transplantation

BACKGROUND

Mitral annular calcification (MAC) is associated with increased risk of major adverse cardiac events. We hypothesized that MAC, identified on a pretransplant transthoracic echocardiography (TTE), is predictive of cardiac events following renal transplantation (RT).

METHODS

In a retrospective cohort of consecutive RT recipients, pretransplant MAC presence and severity were determined on TTE performed within 1 year prior to transplant. MAC severity was quantified based on the circumferential MAC extension relative to the mitral valve annulus. Post-transplant cardiac risk was assessed using the sum of risk factors (range: 0-8) set forth by the American Heart Association/American College of Cardiology Foundation consensus statement on the assessment of RT candidates. Subjects underwent pretransplant stress single-photon emission computed tomography myocardial perfusion imaging and followed for post-transplant composite outcome of cardiac death or myocardial infarction (CD/MI).

RESULTS

Among 336 subjects (60.5% men; mean age 52 ± 12 years), MAC was present in 78 (23%) patients. During a mean follow-up of 3.1 ± 1.9 years, a total of 70 events were observed. Patients with MAC had a higher event rate compared with those without MAC (34.6% versus 17.8%, log-rank P = 0.001). There was a stepwise increase in CD/MI risk with increasing MAC severity (P for trend = 0.002). MAC-associated risk remained significant after adjusting for sex, duration of dialysis, sum of risk factors, ejection fraction and perfusion abnormality burden, providing an incremental prognostic value to these parameters (Δχ2 =4.63; P = 0.031).

CONCLUSION

Among RT recipients, the burden of pretransplant MAC is an independent predictor of post-transplant risk of CD/MI. MAC should be considered in the preoperative assessment of RT candidates.

Valve Calcification in Aortic Stenosis: Etiology and Diagnostic Imaging Techniques

Aortic stenosis is the most common valvulopathy in the Western world. Its prevalence has increased significantly in recent years due to population aging; hence, up to 8% of westerners above the age of 84 now have severe aortic stenosis (Lindroos et al., 1993). This causes increased morbidity and mortality and therein lies the importance of adequate diagnosis and stratification of the degree of severity which allows planning the best therapeutic option in each case. Long understood as a passive age-related degenerative process, it is now considered a rather more complex entity involving mechanisms and factors similar to those of atherosclerosis (Stewart et al., 1997). In this review, we summarize the pathophysiological mechanisms underlying the onset and progression of the disease and analyze the current role of cardiac imaging techniques for diagnosis.

Mitral Annular Calcification and Aortic Valve Calcification May Help in Predicting Significant Coronary Artery Disease

Mitral annular calcification (MAC) and aortic valve calcification (AVC) are manifestations of atherosclerosis. To determine whether mitral annular calcification and aortic valve calcification detected by transthoracic echocardiography (TTE) might help in predicting significant coronary artery disease (CAD), 123 patients with significant CAD and 93 patients without CAD detected by coronary angiography were investigated. MAC and AVC identified CAD with a sensitivity and specificity of 60.2%, 55.9% and 74.8%, 52.7%, respectively, and with a negative and a positive predictive values of 51.5%, 64.3% and 61.3% and 67.6%, respectively. The positive predictive value of MAC was greater than gender, hypertension, and hypercholesterolemia. AVC showed a positive predictive value greater than gender, hypertension, family history, and hypercho lesterolemia. The negative predictive values of MAC and AVC for CAD were greater than those of all risk factors except diabetes mellitus. In conclusion, presence of MAC and AVC on TTE may help in predicting CAD and should be added to conventional risk factors. Absence of MVC and AVC is a stronger predictor for absence of CAD than all conventional risk factors, except diabetes mellitus. Patients with MAC and AVC should be taken into consideration for the presence of significant CAD and thereby for diagnostic and therapeutic interventions in order to improve the prognosis.

Relationship between mean platelet volume and mitral annular calcification

Mitral annular calcification (MAC) is associated with several cardiovascular disorders including coronary artery disease (CAD), atherosclerosis, heart failure, and stroke. MAC and atherosclerosis share similar clinical risk factors for cardiovascular diseases, including age, obesity, hypertension, hyperlipidemia, and diabetes mellitus. The aim of this study was to assess the mean platelet volume (MPV), an indicator of platelet activation in patients with MAC. The study group consisted of 101 patients with MAC. An age, sex, and BMI matched control group was composed of 55 patients who were admitted to the echocardiography laboratory due to suspicion of organic heart disease and eventually found to be free of MAC. We measured platelet indices values in patients and controls. MPV was significantly higher in patients with MAC than in controls (8.9 ± 0.8 versus 8.0 ± 0.9 fl, respectively; P < 0.001) and platelet distribution width (PDW) was significantly higher in patients with MAC than in controls (15.8 ± 1.3 versus 15.0 ± 1.3%, respectively; P < 0.001). MPV was positively correlated with MAC (P < 0.001, r = 0.47), atrial fibrillation (P = 0.01, r = 0.19), left atrial (P = 0.02, r = 0.83) and negatively correlated with platelet count (P = 0.01, r = -0.20). MPV [odds ratio (OR) 3.89; 95% confidence interval (CI) 1.97-7.67; P < 0.0001], and PDW (OR 2.27; 95% CI 1.45-3.55; P < 0.0001) were independently associated with the MAC. We have shown that MPV and PDW were significantly elevated in patients with MAC. MPV was correlated with MAC, atrial fibrillation and left atrial and negatively correlated with platelet count. MPV and PDW were independently associated with MAC.

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.

Prevalence of calcific aortic valve disease in the elderly and associated risk factors: a population-based study in a Mediterranean area

AIMS

To determine the prevalence of aortic valve sclerosis (ASC) and stenosis (AS) in the elderly in a Mediterranean area and to identify associated clinical factors.

METHODS AND RESULTS

Population cross-sectional study in a random sample of 1068 people ≥65 years in a Mediterranean area. ASC was categorized as absent, mild-to-moderate, or moderate-to-severe depending on the severity of thickening and calcification. The relation between the severity of ASC and potential risk factors was assessed by multinomial logistic regression analysis. Some degree of thickening and/or calcification was present in 45.4%, of the sample, 73.5% in >85 years. AS prevalence was 3% for the total cohort and 7.4% in >85 years. Adjusting for gender it was found that age, smoking habit, hypertension, waist circumference, and ankle-brachial index <0.9 were associated with degrees of ASC. Except for waist circumference, there was a gradient between the magnitude of association and the severity of ASC. The OR for age was 1.56 (95% CI 1.39-1.76) for mild-to-moderate ASC and 2.03 (95% CI 1.72-2.4) for moderate-to-severe ASC, and for smoking habit 1.59 (95% CI 1.08-2.34) for mild-to-moderate ASC and 2.13 (95% CI 1.19-3.78) for moderate-to-severe ASC. Diabetes and renal impairment were associated with advanced but not with early stages of ASC.

CONCLUSIONS

The prevalence of ASC and AS in people ≥65 years is similar to that reported in other regions. The gradient in the association of cardiovascular risk factors with the severity of ASC suggests that they may be causally implied in the pathogenesis of the disease.

Prognostic value of echocardiographic-derived calcium index in coronary artery disease diagnosed by 64-multidetector computed tomography

PURPOSE

To determine whether echocardiographic calcium index (ECI) calculated using transthoracic echocardiography (TTE) predicts coronary ischemic events. We also wished to determine coronary artery calcium score (CACS), the presence of obstructive coronary artery disease (CAD) and plaque composition, all of which were assessed by multidetector computed tomography (MDCT).

METHODS

We carried out a prospective cohort study of 82 consecutive outpatients with chest pain and low-moderate risk of CAD, referred for noninvasive coronariography by MDCT. ECI was blindly assessed by TTE and correlated with subsequent cardiovascular events during a follow up period of 36 months.

RESULTS

ECI values of ≥7 had a sensitivity of 77.3%, a specificity of 90%, positive predictive value of 73.9%, and negative predictive value of 91.5% with respect to future coronary ischemic events. In addition, patients with ECI ≥ 7 showed a greater presence of severe calcified and obstructive CAD and a linear increase of obstructed vessels and mixed and calcified plaques, with a linear trend according to ECI values.

CONCLUSION

ECI values of ≥7 determine poor CAD prognosis in relation to ischemic events. Furthermore, ECI ≥ 7 may serve as a marker of content of coronary artery calcium, intraluminal obstruction, and plaque composition. Therefore, ECI seems to provide prognostic information as well as information about the characteristics of the plaque of atheroma.

The impact of mitral annular calcification on left ventricular function in nonagenarians

Background and Objectives

Mitral annular calcification (MAC) is known to be associated with degenerative processes of the cardiac fibrous skeleton and cardiovascular disease mortality. However, MAC has not been evaluated in an extreme age group (patients ≥90 years of age). In this study, the clinical significance of MAC associated with aging was examined in this age group and compared with MAC associated with aging in a younger (20 to 50 years of age) group of patients.

Subjects and Methods

We assessed echocardiographic parameters in 43 nonagenarians and 51 young patients. In the nonagenarian group, patient's age was 92±2 years and 27% were male; in the young control group, patient's age was 36±9 years and 51% were male. Comprehensive M-mode and Doppler echocardiography, including tissue Doppler imaging, were performed. The frequency and severity of MAC was assessed from the leading anterior to the trailing posterior edge at its largest width for least 3 cardiac cycles.

Results

Echocardiography showed that the left ventricular (LV) end-diastolic dimension was larger in the young controls (p=0.007); however, the ejection fraction (EF) was lower in the nonagenarian group (p=0.001). The frequency of MAC was greater in nonagenarians {42/43 (97%)} than in controls {9/51 (17%), p<0.0001}. The maximal width of MAC was larger in nonagenarians (0.52±0.17 mm and 0.05±0.13 mm, p<0.0001). MAC was correlated with LV mass index (g/m²) (r=0.280, p=0.014) and EF (%) (r=-0.340, p=0.001). More importantly, early mitral inflow velocity/early diastolic mitral annulus velocity (E/E') was strongly correlated with MAC in non-agenarians (r= 0.683, p<0.0001).

Conclusion

MAC may be associated with extreme age and increased LV filling pressure in nonagenarians. Further study is necessary to assess the cardiovascular mortality and structural changes related to mitral annulus calcification associated with aging.

Predicting clinically unrecognized coronary artery disease: use of two- dimensional echocardiography

BACKGROUND

2-D Echo is often performed in patients without history of coronary artery disease (CAD). We sought to determine echo features predictive of CAD.

METHODS

2-D Echo of 328 patients without known CAD performed within one year prior to stress myocardial SPECT and angiography were reviewed. Echo features examined were left ventricular and atrial enlargement, LV hypertrophy, wall motion abnormality (WMA), LV ejection fraction (EF) < 50%, mitral annular calcification (MAC) and aortic sclerosis/stenosis (AS). High risk myocardial perfusion abnormality (MPA) was defined as >15% LV perfusion defect or multivessel distribution. Severe coronary artery stenosis (CAS) was defined as left main, 3 VD or 2VD involving proximal LAD.

RESULTS

The mean age was 62 +/- 13 years, 59% men, 29% diabetic (DM) and 148 (45%) had > 2 risk factors. Pharmacologic stress was performed in 109 patients (33%). MPA was present in 200 pts (60%) of which, 137 were high risk. CAS was present in 166 pts (51%), 75 were severe. Of 87 patients with WMA, 83% had MPA and 78% had CAS. Multivariate analysis identified age >65, male, inability to exercise, DM, WMA, MAC and AS as independent predictors of MPA and CAS. Independent predictors of high risk MPA and severe CAS were age, DM, inability to exercise and WMA. 2-D echo findings offered incremental value over clinical information in predicting CAD by angiography. (Chi square: 360 vs. 320 p = 0.02).

CONCLUSION

2-D Echo was valuable in predicting presence of physiological and anatomical CAD in addition to clinical information.

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.

Comparison of prevalence of >70% diameter narrowing of one or more major coronary arteries in patients with versus without mitral annular calcium and clinically suspected coronary artery disease

The prevalence of >70% narrowing of 1, 2, or 3 major coronary arteries and of 3 major coronary arteries was investigated in 2,465 patients (1,437 men, 1,028 women; mean age 69 +/- 13 years) with severe, moderate, mild, or no mitral annular calcium (MAC) diagnosed by 2-dimensional echocardiography who underwent coronary angiography for suspected coronary artery disease. Greater than 70% narrowing of 1, 2, or 3 major coronary arteries was present in 259 of 315 patients (82%) with severe MAC (group 1), in 835 of 1,052 patients (79%) with moderate or mild MAC (group 2), and in 756 of 1,098 patients (69%) with no MAC (group 3) (p <0.001 comparing group 1 with group 3 and group 2 with group 3). Greater than 70% narrowing of 3 major coronary arteries was present in 149 of 315 patients (47%) in group 1, in 366 of 1,052 patients (35%) in group 2, and in 325 of 1,098 patients (30%) in group 3 (p <0.001 comparing group 1 with group 3 and group 1 with group 2; p <0.01 comparing group 2 with group 3). In conclusion, MAC is associated with obstructive >or=1-vessel coronary artery disease and with obstructive 3-vessel coronary artery disease.

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.

Aortic valve sclerosis: a marker of significant obstructive coronary artery disease in patients with chest pain?

BACKGROUND

Previous reports suggested a relationship between coronary artery disease (CAD) and aortic valve sclerosis (AVS). However, whether AVS can be used as a marker of obstructive CAD (obCAD) in patients with chest pain is unknown. We hypothesized that AVS is a predictive marker for obCAD in patients hospitalized for chest pain.

METHODS

We studied 93 consecutive patients with chest pain undergoing coronary angiography. All had negative cardiac enzymes and no previous diagnosis of cardiac ischemic disease. AVS was detected by transthoracic echocardiography. Resting electrocardiography, left ventricular systolic function, wall-motion abnormalities, and stress test results were considered. We calculated the diagnostic value for obCAD of AVS, stress test, and combination of the two methods.

RESULTS

ObCAD was present in 29 patients (31%). Patients with obCAD had a higher prevalence of AVS (38 vs 14%, P = .02) and positive stress test (67 vs 28%, P = .02). The odds ratio for obCAD in the presence of AVS was 3.7 (95% confidence interval 1.3-10.4, P = .01). AVS (P = .01) and a positive stress test (P = .002) were independent predictors for obCAD at the multivariate analysis. AVS had sensitivity of 38% and specificity of 86%. Stress test had sensitivity of 67% and specificity of 72%. When echocardiographic detection of AVS was combined with stress test, the sensitivity and negative predictive value improved to 93% and 96%, respectively.

CONCLUSIONS

AVS is an independent predictor for obCAD in patients with chest pain, thus, it should be considered in the risk stratification of these patients.

Carotid intima–media thickness, carotid distensibility and mitral, aortic valve calcification: a useful diagnostic parameter of systemic atherosclerotic disease

BACKGROUND

Mitral (MAC) and aortic (AVC) calcification are observed more frequently in the elderly and are associated with coronary artery disease, aortic atheroma and peripheral arterial atherosclerotic disease. Common carotid intima-media thickness (cIMT) and distensibility (cDIST) are also independent predictors of adverse cardiovascular outcomes. We examined the relationship between the degree of MAC-AVC and cIMT and cDIST.

METHODS AND RESULTS

One hundred and forty-three patients referred for transthoracic echocardiography and carotid artery echo-Doppler were evaluated; the variables measured were: systemic blood pressure, pulse pressure; body mass index, traditional risk factors, cIMT, cDIST (cDIST = [(csD - cdD)/PP]/csD; where csD and cdD were systolic and diastolic carotid diameters, respectively). MAC and AVC score, based on acoustic densitometry, were: 1 = absence of annular/valvular (av) sclerosis/calcification; 2 = av sclerosis; 3 = av calcification; 4 = av calcification; 5 = av calcification with no recognition of the leaflets; the resulting score was the highest for either valvular annulus. Mean cIMT increased linearly with increasing valvular calcification score (P < 0.0001) whereas cDIST decreased for scores 1 to 5 (P < 0.0001). Distribution of cIMT quartiles showed that 75% of the patients in the lowest quartile had a score of 1 and 70% of patients in the highest quartile had a score of 5; 47% of the patients in the highest quartile of cDIST had a score of 1, whereas 60% of patients in the lowest quartile of cDIST had a score of 4.

CONCLUSIONS

The MAC and AVC score identifies subgroups of patients with different cIMT and cDIST. These data may confirm MAC-AVC as a useful important diagnostic parameter of systemic atherosclerotic disease.

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 sclerosis--a marker of coronary atherosclerosis

Aortic valve sclerosis is defined as calcification and thickening of a trileaflet aortic valve in the absence of obstruction of ventricular outflow. Its frequency increases with age, making it a major geriatric problem. Of adults aged > 65 years, 21-29% exhibit aortic valve sclerosis. Incidence of aortic sclerosis increases with age, male gender, smoking, hypertension, high lipoprotein (Lp) (a), high low-density lipoprotein (LDL), and diabetes mellitus. Aortic valves affected by aortic sclerosis contain a higher amount of oxidized LDL cholesterol and show increased expression of metalloproteinases. Clinically, it can be suspected in the presence of soft ejection systolic murmur at the aortic area, normal split of the second heart sound, and normal volume carotid pulse, but it can be best detected by echocardiography. Aortic sclerosis may be accompanied by mitral annulus calcification up to 50% of cases. It is associated with an increase of approximately 50% in the risk of death from cardiovascular causes and the risk of myocardial infarction. The mechanism by which aortic sclerosis contributes to or is associated with increased cardiovascular risk is not known. Aortic sclerosis is associated with systemic endothelial dysfunction, and a small percentage of cases may progress to aortic stenosis. Lowering of LDL cholesterol by 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors have been shown to decrease progression of aortic valve calcification. Aortic sclerosis is not a mere benign finding. Once diagnosis of aortic sclerosis has been made, it should be considered a potential marker of coexisting coronary disease. Aggressive management of modifiable risk factors, especially LDL cholesterol lowering, may slow progression of the disease.

Aortic valve sclerosis is an echocardiographic indicator of significant coronary disease in patients undergoing diagnostic coronary angiography

Aortic valve sclerosis (AVS) is considered to be a manifestation of generalised atherosclerosis that involves the aortic valve. It has been associated with higher cardiovascular morbidity and mortality in a population-based study. This investigation used transthoracic echocardiography (TTE) to evaluate the prevalence and significance of AVS in 357 Chinese patients with suspected coronary artery disease (CAD). This work reveals that AVS is an independent echocardiographic predictor of significant CAD in such clinical setting (O.R.=3.18; 95% confidence interval 1.52-6.7; p=0.002). Other independent predictors include male gender, diabetes mellitus and hypertriglyceridemia. The predictive value of AVS for the presence of CAD is more prominent in females and in subjects aged <65 years. The recognition of AVS on TTE should alert the physicians to the possibility of underlying significant CAD, and further evaluation with aggressive management is indicated, even though no angiographic documentation is available.

Association of mitral annulus calcification, aortic valve calcification with carotid intima media thickness

Background

Mitral annular calcification (MAC) and aortic annular calcification (AVC) may represent a manifestation of generalized atherosclerosis in the elederly. Alterations in vascular structure, as indexed by the intima media thickness (IMT), are also recognized as independent predictors of adverse cardiovascular outcomes.

Aim

To examine the relationship between the degree of calcification at mitral and/or aortic valve annulus and large artery structure (thickness).

Methods

We evaluated 102 consecutive patients who underwent transthoracic echocardiography and carotid artery echoDoppler for various indications; variables measured were: systemic blood pressure (BP), pulse pressure (PP=SBP-DBP), body mass index (BMI), fasting glucose, total, HDL, LDL chlolesterol, triglycerides, cIMT. The patients were divided according to a grading of valvular/annular lesions independent scores based on acoustic densitometry: 1 = annular/valvular sclerosis/calcification absence; 2 = annular/valvular sclerosis; 3 = annular calcification; 4 = annular-valvular calcification; 5 = valvular calcification with no recognition of the leaflets.

Results

Patient score was the highest observed for either valvular/annulus. Mean cIMT increased linearly with increasing valvular calcification score, ranging from 3.9 ± 0.48 mm in controls to 12.9 ± 1.8 mm in those subjects scored 5 (p < 0.0001). In the first to fourth quartile of cIMT values the respective maximal percentual of score were: score 1: 76.1%, score 2: 70.1%, score 4: 54.3% and score 5: 69.5% (p > 0.0001).

Conclusion

MAC and AVC score can identify subgroups of patients with different cIMT values which indicate different incidence and prevalence of systemic artery diseases. This data may confirm MAC-AVC as a useful important diagnostic parameter of systemic atherosclerotic disease.

Epidemiology and association of vascular and valvular calcium quantified by multidetector computed tomography in elderly asymptomatic subjects

The epidemiology of and association between vascular and valvular calcium as quantified by multidetector computed tomography (MDCT) were studied in 416 elderly subjects with no history of coronary artery disease. Coronary calcium (CC), descending thoracic aortic calcium (DTAC), aortic valve calcium (AVC), and mitral valve calcium (MVC) were present in 282 (68%), 214 (51%), 152 (37%), and 68 (16%) subjects, respectively. Multiple logistic regression analysis showed that after adjusting for age and gender, subjects with AVC (odds ratio [OR] 2.3), MVC (OR 2.81), and DTAC (OR 2.79) were independently and significantly more likely to have CC. Further evidence is provided for the notion that calcifications in those regions are associated and that MDCT can be used as a tool for the global assessment of vascular and valvular calcium.

Mitral annular calcification is a predictor for incident atrial fibrillation

BACKGROUND

Mitral annular calcification (MAC) has been associated with adverse cardiovascular disease outcomes and stroke in longitudinal and community-based cohorts. Prospective data are limited on its association with atrial fibrillation (AF).

METHODS

We examined the association between MAC and the long-term risk of AF over 16 years of follow-up in participants in the original cohort of the Framingham Heart Study who attended a routine examination between 1979 and 1981. MAC was assessed by M-mode echocardiography. cox proportional-hazards models were used to estimate hazard ratios (hr) for incident af.

RESULTS

Of 1126 subjects who had adequate echocardiographic assessment and were AF-free at baseline, 149 (13%) had MAC. There were 217 cases of incident AF (42 in subjects with MAC). The age- and sex-adjusted incidence rate was 362 per 10,000 person-years in subjects with MAC compared with 185 per 10,000 person-years in those without MAC. In multivariable-adjusted analyses, MAC was associated with an increased risk of AF (HR 1.6, 95% CI 1.1-2.2). This association was attenuated upon further adjustment for left atrial size (HR 1.4, 95% CI 0.9-2.0).

CONCLUSIONS

The association between MAC and incident AF may be mediated partially through left atrial enlargement. These data suggest the importance of better understanding the mechanisms involved in cardiac valvular calcification.

[Echocardiography in elderly patients]

IN THE CONTEXT OF AGEING: The Doppler echocardiography is a non-invasive technique that permits assessment of the "physiological" ageing of the cardiac and vascular structures, notably including a concentric remodelling of the left ventricle associated with relaxation abnormalities, dilatation of the left atrium, valvular reorganisation and a modification in the large vessels. IN A PATHOLOGICAL CONTEXT: The Doppler echocardiography also detects the various cardiovascular affections related to ageing: valvulopathies, notably calcified aortic stenosis and mitral failure due to mitral anulus calcification or prolapsus of the valve; primary hypertrophic cardiomyopathy or secondary to arterial hypertension or an amyloidosis, and possibly leading to heart failure with spared systolic function, frequent in elderly patients; ischemic cardiopathies that have benefited, as in younger patient, from new echographical stress testing techniques, which safely study the variability in myocardial ischemia. Transoesophageal echography can also be performed in elderly patients, but the indications of this more invasive and less well-tolerated examination must be assessed case by case. It is very useful when an intra-parietal aortic hematoma is suspected or during aortic dissection or infectious endocarditis.

Aortic valve calcification in hypertensive patients: prevalence, risk factors and association with transvalvular flow velocity

BACKGROUND

The important role of the "nonobstructive" aortic valve calcification (AVC) in cardiovascular morbidity and mortality has recently been emphasized. The present work had two goals: (1) to analyze the prevalence and factors determining the extent of AVC in hypertensive patients; (2) to investigate a possible association between the extent of AVC and flow velocity across the aortic valve.

METHODS

This was a prospective study performed in a university hospital. The sample included 263 consecutive patients (139 men and 124 women), mean age 65+/-6, who underwent echo-Doppler. The upper quartile of peak flow velocity across the aortic valve (>130 mm/s in our population) was defined as augmented flow velocity.

RESULTS

There were 31 (12%) patients in the advanced AVC group and 122 (46%) without any calcified deposits (the no AVC group). The remaining 110 (42%), who did not meet criteria for advanced AVC, comprised the trivial AVC group. Peak flow velocity was significantly higher in patients with advanced vs. trivial AVC and no AVC groups: 135+/-45, 116+/-23 and 113+/-23 cm/s, respectively; p=0.0002. Prevalence of augmented transvalvular aortic flow was significantly higher (p=0.01) among patients with advanced AVC (41.9%) vs. trivial (20.9%) and no AVC (20.5%). Multivariate analyses identified age as the only independent variable associated with advanced AVC [OR 1.6 (CI 1.2-2.3), 5 years increment]. Advanced AVC and female gender were identified as independent variables for augmented transvalvular aortic flow with OR 2.9 (CI 1.3-6.4) and 2.5 (CI 1.4-4.6), respectively.

CONCLUSIONS

Prevalence of AVC among hypertensive patients is high and clearly age-related. Female gender and advanced (but not trivial) AVC are associated with augmented aortic transvalvular peak flow. Our results stress the role of protruding calcium deposits in augmentation of rest flow velocity across the aortic valve regardless of visible restriction of leaflet opening.

Is Carotid Atherosclerosis More Important in Patients With Mitral Annular Calcification Than in Those Without?

It has been suggested that mitral annular calcification (MAC) may be a manifestation of generalized atherosclerosis. However, how the incidence and extent of coronary artery disease (CAD) are affected by the coexistence of carotid atherosclerosis (CAS) in patients with versus without MAC have not yet been studied. We studied 101 patients with echocardiographic MAC and 52 controls without MAC to investigate the clinical impact of CAS on the frequency and severity (defined as the number of obstructed vessels) of CAD in patients with MAC. Carotid Doppler ultrasonographic examination was performed on all patients before coronary angiography. In patients with both MAC and CAS, the incidences of CAD and multivessel disease (> or = 2 vessel or left main coronary artery disease) were significantly higher than in the control group with CAS alone (91% versus 68%, P = 0.008 and 76% versus 44%, P = 0.004, respectively). On the other hand, among study and control patients without CAS, although the frequencies of CAD and multivessel disease were higher in patients with MAC, interestingly, the differences were not statistically significant (37% versus 58% and 15% versus 26%, respectively, P > 0.05 for both). Stepwise multiple logistic regression analysis revealed that CAS (P < 0.001), MAC (P < 0.01) and, to a limited extent hypertension (P = 0.054), were independent predictors for the presence of CAD. In conclusion, the coexistence of CAS is more important in patients with MAC than in those without as it provides valuable information about the incidence and severity of underlying CAD. In cases with MAC but without CAS, MAC could be caused by factors other than atherosclerosis.

Mitral annular calcification predicts cardiovascular morbidity and mortality: the Framingham Heart Study

BACKGROUND

Mitral annular calcification (MAC) has been associated with stroke in longitudinal, community-based cohorts and cardiovascular disease (CVD) outcomes in many small retrospective studies. Prospective data are limited on the relation of MAC with CVD morbidity and mortality.

METHODS AND RESULTS

We examined the association between MAC assessed by M-mode echocardiography and the incidence of CVD, CVD death, and all-cause death over 16 years of follow-up in the Framingham Heart Study subjects who attended a routine examination between 1979 and 1981. Cox proportional hazards models were used to estimate hazard ratios (HRs) associated with the presence of MAC for each outcome. Of 1197(445 male, 752 female) subjects who had adequate echocardiographic assessment, 14% had MAC. There were 307 incident CVD events and 621 deaths. In multivariable adjusted analyses, MAC was associated with an increased risk of incident CVD (HR, 1.5; 95% CI, 1.1, 2.0), CVD death (HR, 1.6; 95% CI, 1.1, 2.3), and all-cause death (HR, 1.3; 95% CI, 1.04, 1.6). For each 1-mm increase in MAC, the risk of incident CVD, CVD death, and all-cause death increased by approximately 10%.

CONCLUSIONS

The independent association of MAC with incident CVD and CVD death underscores that cardiac calcification is a marker of increased CVD risk.

Aortic valve sclerosis is associated with systemic endothelial dysfunction

OBJECTIVES

We sought to examine the association between aortic valve sclerosis (AVS) and systemic endothelial manifestations of the atherosclerotic process.

BACKGROUND

Clinical and experimental studies suggest that AVS is a manifestation of the atherosclerotic process. Systemic endothelial dysfunction is an early sign of the atherosclerotic process and can be assessed by ultrasonography of the brachial artery.

METHODS

A total of 102 in-hospital patients (76 men; mean age 63.5 +/- 9.7 years) referred to the stress echocardiography laboratory underwent: 1) transthoracic echocardiography, with specific assessment of AVS (thickened valve leaflets with a transaortic flow velocity <2.5 m/s); 2) stress echocardiography; 3) coronary angiography, with evaluation of the Duke score (from 0 [normal] to 100 [most severe disease]); and 4) an endothelial function study, with assessment of endothelium-dependent, post-ischemic, flow-mediated dilation (FMD).

RESULTS

Aortic valve sclerosis was present in 35 patients (group I) and absent in 67 (group II). Groups I and II were similar in terms of the frequency of stress-induced wall motion abnormalities (35.3% vs. 19.4%, p = NS) and the angiographic Duke score (33.8 +/- 28.6 vs. 35.2 +/- 29.1, p = NS). Patients with AVS showed a markedly lower FMD than those without AVS (2.2 +/- 3.5% vs. 5.3 +/- 5.3%, p < 0.01). On multivariate analysis, only FMD was highly predictive of AVS, with an odds ratio of 1.18 for each percent decrease in FMD (95% confidence interval 1.05 to 1.32; p = 0.01).

CONCLUSIONS

Aortic valve stenosis is associated with systemic endothelial dysfunction. This observation may provide a mechanistic insight into the emerging association between AVS and cardiovascular events.

Association of mitral annulus calcification, aortic valve sclerosis and aortic root calcification with abnormal myocardial perfusion single photon emission tomography in subjects age < or =65 years old

OBJECTIVES

We examined the hypothesis that mitral annulus calcification (MAC), aortic valve sclerosis (AVS) and aortic root calcification (ARC) are associated with coronary artery disease (CAD) in subjects age < or =65 years.

BACKGROUND

Mitral annulus calcification, AVS and ARC frequently coexist and are associated with coronary risk factors and CAD in the elderly.

METHODS

We studied 338 subjects age < or =65 years who underwent evaluation of chest pain with myocardial perfusion single photon emission computed tomography (SPECT) and a two-dimensional transthoracic echocardiogram for other indications. The association of MAC, AVS and ARC with abnormal SPECT was evaluated by using chi-square analyses and logistic regression analyses.

RESULTS

Compared with no or one calcium deposit and no or one coronary risk factor other than diabetes, multiple (> or =2) calcium (or sclerosis) deposits with diabetes or multiple (> or =2) coronary risk factors were significantly associated with abnormal SPECT in women age < or =55 years old (odds ratio [OR], 20.00), in women age >55 years old (OR, 10.00) and in men age < or =55 years old (OR, 5.55). Multivariate analyses identified multiple calcium deposits as a significant predictor for an abnormal SPECT in women (p < 0.001), younger subjects age < or =55 years (p < 0.05) and the total group of subjects (p < 0.01).

CONCLUSIONS

When coronary risk factors are also taken into consideration, the presence of multiple calcium deposits in the mitral annulus, aortic valve or aortic root appears to be a marker of CAD in men < or =55 years old and women.

Rate of progression of valvular aortic stenosis in patients > or = 60 years of age

A retrospective analysis of 171 women and 119 men, mean age 76 +/- 9 years, with aortic stenosis diagnosed by Doppler echocardiography, who had follow-up Doppler echocardiograms, showed that the reduction in aortic valve area per year was not significantly different in older persons with mild, moderate, and severe aortic stenosis. The decrease in aortic valve area per year was significantly greater in men 60 to 74 years old than in women 60 to 74 years old (p = 0.025), in women > or =75 years old than in women 60 to 74 years old (p = 0.006), and in persons with mitral annular calcium than in persons without mitral annular calcium (p = 0.046).