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Brunetti E, Lucà F, Presta R, Marchionni N, Boccanelli A, Ungar A, Rao CM, Ingianni N, Lettino M, Del Sindaco D, Murrone A, Riccio C, Colivicchi F, Grimaldi M, Gulizia MM, Oliva F, Bo M, Parrini I. A Comprehensive Geriatric Workup and Frailty Assessment in Older Patients with Severe Aortic Stenosis. J Clin Med 2024; 13:4169. [PMID: 39064209 PMCID: PMC11278149 DOI: 10.3390/jcm13144169] [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: 05/09/2024] [Revised: 07/04/2024] [Accepted: 07/09/2024] [Indexed: 07/28/2024] Open
Abstract
Aortic stenosis (AS) represents a notable paradigm for cardiovascular (CV) and geriatric disorders owing to comorbidity. Transcatheter aortic valve replacement (TAVR) was initially considered a therapeutic strategy in elderly individuals deemed unsuitable for or at high risk of surgical valve replacement. The progressive improvement in TAVR technology has led to the need to refine older patients' stratification, progressively incorporating the concept of frailty and other geriatric vulnerabilities. Recognizing the intricate nature of the aging process, reliance exclusively on chronological age for stratification resulted in an initial but inadequate tool to assess both CV and non-CV risks effectively. A comprehensive geriatric evaluation should be performed before TAVR procedures, taking into account both physical and cognitive capabilities and post-procedural outcomes through a multidisciplinary framework. This review adopts a multidisciplinary perspective to delve into the diagnosis and holistic management of AS in elderly populations in order to facilitate decision-making, thereby optimizing outcomes centered around patient well-being.
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Affiliation(s)
- Enrico Brunetti
- Geriatric Unit, Department of Medical Sciences, University of Turin, Hospital Città della Salute e della Scienza di Torino, 10126 Turin, Italy (R.P.); (M.B.)
- Department of Experimental and Clinical Medicine, University of Florence, Largo G. Brambilla 3, 50134 Florence, Italy
| | - Fabiana Lucà
- Cardiology Department, Grande Ospedale Metropolitano di Reggio, 89124 Reggio Calabria, Italy
| | - Roberto Presta
- Geriatric Unit, Department of Medical Sciences, University of Turin, Hospital Città della Salute e della Scienza di Torino, 10126 Turin, Italy (R.P.); (M.B.)
| | - Niccolò Marchionni
- Department of Experimental and Clinical Medicine, University of Florence, Largo G. Brambilla 3, 50134 Florence, Italy
| | | | - Andrea Ungar
- Department of Experimental and Clinical Medicine, University of Florence, Largo G. Brambilla 3, 50134 Florence, Italy
| | | | | | - Maddalena Lettino
- Department for Cardiac, Thoracic and Vascular Diseases, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy
| | | | - Adriano Murrone
- S.C. Cardiologia-UTIC, Ospedali di Città di Castello e di Gubbio-Gualdo Tadino, AUSL Umbria 1, 06127 Perugia, Italy
| | - Carmine Riccio
- Division of Clinical Cardiology, A.O.R.N. ‘Sant’Anna e San Sebastiano’, 81100 Caserta, Italy
| | - Furio Colivicchi
- Clinical and Rehabilitation Cardiology Unit, San Filippo Neri Hospital, 00135 Rome, Italy
| | - Massimo Grimaldi
- Cardiology Department, Miulli Hospital, Acquaviva delle Fonti, 70021 Bari, Italy
| | | | - Fabrizio Oliva
- Cardiovascular Department “A. De Gasperis”, ASST Niguarda Hospital, 20162 Milano, Italy
| | - Mario Bo
- Geriatric Unit, Department of Medical Sciences, University of Turin, Hospital Città della Salute e della Scienza di Torino, 10126 Turin, Italy (R.P.); (M.B.)
| | - Iris Parrini
- Department of Cardiology, Mauriziano Hospital, 10128 Turin, Italy
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Bleiziffer S, Appleby C, Delgado V, Eltchaninoff H, Gebhard C, Hengstenberg C, Wojakowski W, Petersen N, Kurucova J, Bramlage P, Rudolph TK. Patterns of aortic valve replacement in Europe and adoption by sex. Int J Cardiol 2024; 406:131996. [PMID: 38555056 DOI: 10.1016/j.ijcard.2024.131996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 03/20/2024] [Accepted: 03/27/2024] [Indexed: 04/02/2024]
Abstract
OBJECTIVE Management of patients with severe aortic stenosis (AS) may differ according to the patient sex. This study aimed to describe patterns of aortic valve replacement (AVR) for severe AS across Europe, including stratification by sex. METHODS Procedure volume data for surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI) for six years (2015-2020) were extracted from national databases for Austria, Czech Republic, Denmark, England, Finland, France, Germany, Norway, Poland, Spain, Sweden, and Switzerland and stratified by sex. Patients per million population (PPM) undergoing AVR per year were calculated using population estimates from Eurostat. RESULTS Between 2015 and 2019, AVR procedures grew at an average annual rate of 3.9%. In 2020, the average total PPM undergoing AVR across all countries was 339, with 51% of procedures being TAVI and 49% SAVR. AVR PPM varied widely between countries, with the highest and lowest in Germany and Poland, respectively. The average total PPM was higher for men than women (423 vs. 258), but a higher proportion of women (62%) than men (44%) received TAVI. The proportion of TAVI among total AVR procedures increased with age, with an overall average of 96% of men and 98% of women aged ≥85 years receiving TAVI; however, adoption of TAVI varied by country. CONCLUSIONS The analysis of temporal trends in the adoption of TAVI vs. SAVR across Europe showed significant variations. Despite the higher use of TAVI vs. SAVR in women, overall rates of AV intervention in women were lower compared to men.
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Affiliation(s)
- Sabine Bleiziffer
- Department of Thoracic and Cardiovascular Surgery, Heart and Diabetes Centre, North Rhine-Westphalia, University Hospital, Ruhr-University Bochum, Bad Oeynhausen, Germany.
| | - Clare Appleby
- Department of Cardiology, Liverpool Heart and Chest Hospital, Thomas Dr, Liverpool L14 3PE, UK.
| | - Victoria Delgado
- Heart Institute, Department of Cardiology, Hospital University Germans Trias i Pujol Barcelona, Spain.
| | - Helene Eltchaninoff
- Department of Cardiology, Normandie Univ, UNIROUEN, U1096, CHU Rouen, F-76000 Rouen, France.
| | - Catherine Gebhard
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010 Bern, Switzerland.
| | - Christian Hengstenberg
- Division of Cardiology, Department of Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.
| | - Wojtek Wojakowski
- Division of Cardiology and Structural Heart Diseases, Medical University of Silesia, Ziolowa 45/47, Katowice 40-635, Poland.
| | | | | | - Peter Bramlage
- Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany.
| | - Tanja K Rudolph
- General and Interventional Cardiology/Angiology, Heart and Diabetes Centre, North Rhine-Westphalia, Bad Oeynhausen, Ruhr-University, Germany.
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Bae JY, Fallahi A, Miller W, Leon MB, Abraham TP, Bangalore S, Hsi DH. A call to consider an aortic stenosis screening program. Trends Cardiovasc Med 2024; 34:297-301. [PMID: 37105278 DOI: 10.1016/j.tcm.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 04/16/2023] [Accepted: 04/23/2023] [Indexed: 04/29/2023]
Abstract
Aortic stenosis (AS) is the most common age-related valvular condition with a prevalence of 13.1% in patients older than 75 years of age. Based on the severity of AS and symptoms, current guidelines recommend interval monitoring with transthoracic echocardiogram (TTE). However, no guidelines exist regarding screening asymptomatic persons for AS. Prevalence of AS is comparable to conditions such as colorectal cancer, lung cancer, breast cancer, and abdominal aortic aneurysm where dedicated screening programs are offered resulting in reduction of overall morbidity and mortality. We review recent advancements in treatment options, and we propose an AS screening program for high-risk individuals without known history of AS including all persons over age 75 and persons aged 70 years and older with dialysis dependent end-stage renal disease (ESRD).
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Affiliation(s)
- Ju Young Bae
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale New Haven Health Bridgeport Hospital, Bridgeport, CT, United States
| | - Arzhang Fallahi
- Heart & Vascular Institute, Stamford Hospital, Stamford, CT, United States
| | - Wayne Miller
- Heart & Vascular Institute, Stamford Hospital, Stamford, CT, United States
| | - Martin B Leon
- Columbia University Medical Center/New York Presbyterian Hospital, University of Columbia College of Physicians and Surgeons, New York, NY, United States
| | - Theodore P Abraham
- University of California San Francisco Medical Center, CA, United States
| | - Sripal Bangalore
- New York University Grossman School of Medicine, New York, NY, United States
| | - David H Hsi
- Heart & Vascular Institute, Stamford Hospital, Stamford, CT, United States.
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Benfari G, Essayagh B, Michelena HI, Ye Z, Inojosa JM, Ribichini FL, Crestanello J, Messika-Zeitoun D, Prendergast B, Wong BF, Thapa P, Enriquez-Sarano M. Severe aortic stenosis: secular trends of incidence and outcomes. Eur Heart J 2024; 45:1877-1886. [PMID: 38190428 DOI: 10.1093/eurheartj/ehad887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 11/17/2023] [Accepted: 12/21/2023] [Indexed: 01/10/2024] Open
Abstract
BACKGROUND AND AIMS Severe aortic stenosis (AS) is the guideline-based indication for aortic valve replacement (AVR), which has markedly increased with transcatheter approaches, suggesting possible increasing AS incidence. However, reported secular trends of AS incidence remain contradictory and lack quantitative Doppler echocardiographic ascertainment. METHODS All adults residents in Olmsted County (MN, USA) diagnosed over 20 years (1997-2016) with incident severe AS (first diagnosis) based on quantitatively defined measures (aortic valve area ≤ 1 cm2, aortic valve area index ≤ 0.6 cm2/m2, mean gradient ≥ 40 mmHg, peak velocity ≥ 4 m/s, Doppler velocity index ≤ 0.25) were counted to define trends in incidence, presentation, treatment, and outcome. RESULTS Incident severe AS was diagnosed in 1069 community residents. The incidence rate was 52.5 [49.4-55.8] per 100 000 patient-year, slightly higher in males vs. females and was almost unchanged after age and sex adjustment for the US population 53.8 [50.6-57.0] per 100 000 residents/year. Over 20 years, severe AS incidence remained stable (P = .2) but absolute burden of incident cases markedly increased (P = .0004) due to population growth. Incidence trend differed by sex, stable in men (incidence rate ratio 0.99, P = .7) but declining in women (incidence rate ratio 0.93, P = .02). Over the study, AS clinical characteristics remained remarkably stable and AVR performance grew and was more prompt (from 1.3 [0.1-3.3] years in 1997-2000 to 0.5 [0.2-2.1] years in 2013-16, P = .001) but undertreatment remained prominent (>40%). Early AVR was associated with survival benefit (adjusted hazard ratio 0.55 [0.42-0.71], P < .0001). Despite these improvements, overall mortality (3-month 8% and 3-year 36%), was swift, considerable and unabated (all P ≥ .4) throughout the study. CONCLUSIONS Over 20 years, the population incidence of severe AS remained stable with increased absolute case burden related to population growth. Despite stable severe AS presentation, AVR performance grew notably, but while declining, undertreatment remained substantial and disease lethality did not yet decline. These population-based findings have important implications for improving AS management pathways.
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Affiliation(s)
- Giovanni Benfari
- Department ofCardiovascular Disease, Mayo Clinic, Rochester, MN, USA
- Section of Cardiology, University of Verona, Verona, Italy
| | - Benjamin Essayagh
- Department ofCardiovascular Disease, Mayo Clinic, Rochester, MN, USA
- Department of Echocardiography, Cardio X Clinic, Cannes, France
| | | | - Zi Ye
- Department ofCardiovascular Disease, Mayo Clinic, Rochester, MN, USA
| | | | | | - Juan Crestanello
- Department ofCardiovascular Disease, Mayo Clinic, Rochester, MN, USA
| | - David Messika-Zeitoun
- Department of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Bernard Prendergast
- Department of Cardiology, Cleveland Clinic and Saint Thomas' Hospitals, London, UK
| | | | - Prabin Thapa
- Department ofCardiovascular Disease, Mayo Clinic, Rochester, MN, USA
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Playford D, Strange GA, Atherton JJ, Harris S, Chan YK, Stewart S. Clinical to Population Prevalence of Hypertrophic Cardiomyopathy Phenotype: Insights From the National Echo Database Australia. Heart Lung Circ 2024; 33:212-221. [PMID: 38177016 DOI: 10.1016/j.hlc.2023.10.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 10/22/2023] [Accepted: 10/29/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND There is a paucity of data describing the underlying prevalence of hypertrophic cardiomyopathy (HCM), a primary genetic disorder characterised by progressive left ventricular (LV) hypertrophy and sudden death, from both a clinical and a population perspective. METHODS We screened the echocardiographic reports of 155,668 men and 147,880 women within the multicentre National Echo Database Australia (NEDA) (2001-2019). End-diastolic wall thickness ≥15 mm anywhere in the left ventricle was identified as a characteristic of an HCM phenotype according to current guideline recommendations. Applying a septal-to-posterior wall thickness ratio >1.3 and LV outflow tract obstruction ≥30 mmHg (when documented), we further identified asymmetric septal hypertrophy and obstructive HCM (oHCM), respectively. The observed pattern of phenotypical HCM within the overall NEDA cohort (>650,000 cases) was then extrapolated to the ∼539,000 (5.7% of adult population) and ∼474,000 (4.8%) Australian men and women, respectively, who were investigated with echocardiography in 2021 on an age-specific basis. RESULTS Overall, 15,380 cases (mean age 71.1±14.6 years, 10,138 men [65.9%]) with the characteristic HCM phenotype within the NEDA cohort were identified. Of these 15,380 cases, 5,552 (36.1%) had asymmetric septal hypertrophy, and 2,276 of the 10,290 cases with LV outflow tract obstruction profiling data (22.1%) had obstructive HCM. A further 3,389 of 13,715 cases (24.7%) had evidence of LV systolic dysfunction (LV ejection fraction <55%). Within the entire NEDA cohort (including those without LV profiling), HCM was found in 10,138 of 342,161 men (2.96%; 95% confidence interval [CI] 2.91%-3.02%) and 5,242 of 308,539 women (1.70%; 95% CI 1.65%-1.75%). When extrapolated to the Australian population, we estimate that a minimum of 15,971 men and 8,057 women presented with echocardiographic features of phenotypical HCM in 2021. This translates into a minimum caseload/prevalence of ∼17 adult men (∼2.5 in those aged ≤50 years) and eight adult women (∼1 in those aged ≤50 years) per 10,000 population meeting phenotypical HCM criteria. CONCLUSIONS Using contemporary Australian echocardiographic and population data, we estimate that a minimum of 15,971 (17.5 cases/10,000) men and 8,057 women (8.2 cases/10,000) had echocardiographic evidence of phenotypical HCM in 2021. These disease burden data are particularly relevant as new treatment options are emerging.
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Affiliation(s)
- David Playford
- Institute for Health Research, University of Notre Dame Australia, Fremantle, WA, Australia.
| | - Geoff A Strange
- Institute for Health Research, University of Notre Dame Australia, Fremantle, WA, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - John J Atherton
- Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia; Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Sarah Harris
- Institute for Health Research, University of Notre Dame Australia, Fremantle, WA, Australia
| | - Yih-Kai Chan
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Vic, Australia
| | - Simon Stewart
- Institute for Health Research, University of Notre Dame Australia, Fremantle, WA, Australia; School of Medicine, Dentistry & Nursing, University of Glasgow, Glasgow, UK
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Irtyuga O, Babakekhyan M, Kostareva A, Uspensky V, Gordeev M, Faggian G, Malashicheva A, Metsker O, Shlyakhto E, Kopanitsa G. Analysis of Prevalence and Clinical Features of Aortic Stenosis in Patients with and without Bicuspid Aortic Valve Using Machine Learning Methods. J Pers Med 2023; 13:1588. [PMID: 38003903 PMCID: PMC10671965 DOI: 10.3390/jpm13111588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 11/02/2023] [Accepted: 11/04/2023] [Indexed: 11/26/2023] Open
Abstract
Aortic stenosis (AS) is the most commonly diagnosed valvular heart disease, and its prevalence increases with the aging of the general population. However, AS is often diagnosed at a severe stage, necessitating surgical treatment, due to its long asymptomatic period. The objective of this study was to analyze the frequency of AS in a population of cardiovascular patients using echocardiography (ECHO) and to identify clinical factors and features associated with these patient groups. We utilized machine learning methods to analyze 84,851 echocardiograms performed between 2010 and 2018 at the National Medical Research Center named after V.A. Almazov. The primary indications for ECHO were coronary artery disease (CAD) and hypertension (HP), accounting for 33.5% and 14.2% of the cases, respectively. The frequency of AS was found to be 13.26% among the patients (n = 11,252). Within our study, 1544 patients had a bicuspid aortic valve (BAV), while 83,316 patients had a tricuspid aortic valve (TAV). BAV patients were observed to be younger compared to TAV patients. AS was more prevalent in the BAV group (59%) compared to the TAV group (12%), with a p-value of <0.0001. By employing a machine learning algorithm, we randomly identified significant features present in AS patients, including age, hypertension (HP), aortic regurgitation (AR), ascending aortic dilatation (AscAD), and BAV. These findings could serve as additional indications for earlier observation and more frequent ECHO in specific patient groups for the earlier detection of developing AS.
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Affiliation(s)
- Olga Irtyuga
- Almazov National Medical Research Centre, 197341 Saint-Petersburg, Russia; (O.I.); (M.B.); (A.K.); (V.U.); (M.G.); (A.M.); (O.M.); (E.S.)
| | - Mary Babakekhyan
- Almazov National Medical Research Centre, 197341 Saint-Petersburg, Russia; (O.I.); (M.B.); (A.K.); (V.U.); (M.G.); (A.M.); (O.M.); (E.S.)
| | - Anna Kostareva
- Almazov National Medical Research Centre, 197341 Saint-Petersburg, Russia; (O.I.); (M.B.); (A.K.); (V.U.); (M.G.); (A.M.); (O.M.); (E.S.)
| | - Vladimir Uspensky
- Almazov National Medical Research Centre, 197341 Saint-Petersburg, Russia; (O.I.); (M.B.); (A.K.); (V.U.); (M.G.); (A.M.); (O.M.); (E.S.)
| | - Michail Gordeev
- Almazov National Medical Research Centre, 197341 Saint-Petersburg, Russia; (O.I.); (M.B.); (A.K.); (V.U.); (M.G.); (A.M.); (O.M.); (E.S.)
| | - Giuseppe Faggian
- Department of Cardiac Surgery, University of Verona Medical School, 37134 Verona, Italy;
| | - Anna Malashicheva
- Almazov National Medical Research Centre, 197341 Saint-Petersburg, Russia; (O.I.); (M.B.); (A.K.); (V.U.); (M.G.); (A.M.); (O.M.); (E.S.)
| | - Oleg Metsker
- Almazov National Medical Research Centre, 197341 Saint-Petersburg, Russia; (O.I.); (M.B.); (A.K.); (V.U.); (M.G.); (A.M.); (O.M.); (E.S.)
| | - Evgeny Shlyakhto
- Almazov National Medical Research Centre, 197341 Saint-Petersburg, Russia; (O.I.); (M.B.); (A.K.); (V.U.); (M.G.); (A.M.); (O.M.); (E.S.)
| | - Georgy Kopanitsa
- Almazov National Medical Research Centre, 197341 Saint-Petersburg, Russia; (O.I.); (M.B.); (A.K.); (V.U.); (M.G.); (A.M.); (O.M.); (E.S.)
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Strange G, Stewart S, Watts A, Playford D. Enhanced detection of severe aortic stenosis via artificial intelligence: a clinical cohort study. Open Heart 2023; 10:e002265. [PMID: 37491129 PMCID: PMC10373677 DOI: 10.1136/openhrt-2023-002265] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 06/30/2023] [Indexed: 07/27/2023] Open
Abstract
OBJECTIVE We developed an artificial intelligence decision support algorithm (AI-DSA) that uses routine echocardiographic measurements to identify severe aortic stenosis (AS) phenotypes associated with high mortality. METHODS 631 824 individuals with 1.08 million echocardiograms were randomly spilt into two groups. Data from 442 276 individuals (70%) entered a Mixture Density Network (MDN) model to train an AI-DSA to predict an aortic valve area <1 cm2, excluding all left ventricular outflow tract velocity or dimension measurements and then using the remainder of echocardiographic measurement data. The optimal probability threshold for severe AS detection was identified at the f1 score probability of 0.235. An automated feature also ensured detection of guideline-defined severe AS. The AI-DSA's performance was independently evaluated in 184 301 (30%) individuals. RESULTS The area under receiver operating characteristic curve for the AI-DSA to detect severe AS was 0.986 (95% CI 0.985 to 0.987) with 4622/88 199 (5.2%) individuals (79.0±11.9 years, 52.4% women) categorised as 'high-probability' severe AS. Of these, 3566 (77.2%) met guideline-defined severe AS. Compared with the AI-derived low-probability AS group (19.2% mortality), the age-adjusted and sex-adjusted OR for actual 5-year mortality was 2.41 (95% CI 2.13 to 2.73) in the high probability AS group (67.9% mortality)-5-year mortality being slightly higher in those with guideline-defined severe AS (69.1% vs 64.4%; age-adjusted and sex-adjusted OR 1.26 (95% CI 1.04 to 1.53), p=0.021). CONCLUSIONS An AI-DSA can identify the echocardiographic measurement characteristics of AS associated with poor survival (with not all cases guideline defined). Deployment of this tool in routine clinical practice could improve expedited identification of severe AS cases and more timely referral for therapy.
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Affiliation(s)
- Geoff Strange
- Cardiology, Heart Research Institute Ltd, Newtown, New South Wales, Australia
- The University of Notre Dame Australia, School of Medicine, Fremantle, Western Australia, Australia
| | - Simon Stewart
- Institute for Health Research, The University of Notre Dame Australia, Fremantle, Western Australia, Australia
- School of Medicine, Dentistry & Nursing, University of Glasgow, Glasgow, UK
| | - Andrew Watts
- Echo IQ Pty Ltd, Sydney, New South Wales, Australia
| | - David Playford
- School of Medicine, The University of Notre Dame Australia, Fremantle, Western Australia, Australia
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Playford D, Schwarz N, Chowdhury E, Williamson A, Duong M, Kearney L, Stewart S, Strange G. Comorbidities and Symptom Status in Moderate and Severe Aortic Stenosis: A Multicenter Clinical Cohort Study. JACC. ADVANCES 2023; 2:100356. [PMID: 38938261 PMCID: PMC11198361 DOI: 10.1016/j.jacadv.2023.100356] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 03/28/2023] [Accepted: 03/31/2023] [Indexed: 06/29/2024]
Abstract
Background Symptoms associated with severe aortic stenosis (AS) are used to guide management. Objectives The purpose of this study was to examine the pattern of symptoms, comorbidities, and cardiac damage in moderate and severe AS. Methods A total of 846,198 echocardiographic investigations from 330,940 individuals aged >18 years were selected for the most recent echocardiogram, moderate or severe AS (mean gradient 20.0-39.9 mm Hg, aortic valve peak gradient 3.0-3.9 m/s and aortic valve area >1.0 cm2; or ≥ 40.0 mm Hg, ≥4.0 m/s or ≤1.0 cm2, respectively), and a cardiologist consultation. Natural Language Processing was applied to letters to extract comorbidities, dyspnea, chest pain, and syncope. Patients with prior aortic valve replacement were excluded. Results 2,213 patients (0.7% overall, 32.8% females) had moderate and 3,416 (1.0%, 47.3% females) had severe AS. Comorbidities were common, including hypertension, (56.6% moderate AS, 53.1% severe AS, P = 0.01), coronary disease (46.0% and 46.8%, respectively, P = 0.58) and atrial fibrillation (29.6% and 34.8%, respectively, P < 0.001). Symptoms were also common in both moderate (n = 915, 41.3%) and severe (n = 1,630, 47.7%) AS (P < 0.001). Comorbidities were more likely in symptomatic vs asymptomatic patients (P < 0.001). Dyspnea was more likely in severe AS, whereas angina and syncope were similar in moderate vs severe AS. In multivariable analysis, only dyspnea was associated with severe (vs moderate) AS (OR: 1.73, 95% CI: 1.41-2.13, P < 0.001). In both adjusted and unadjusted models, the degree of cardiac damage did not relate to presence of any symptoms but was associated with AS severity. Conclusions Dyspnea is common in both moderate and severe AS, is associated with comorbidities and is not related to the degree of cardiac damage. Symptom-guided management decisions in AS may need revision.
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Affiliation(s)
- David Playford
- Advara Heart Care, Leabrook, Adelaide, Australia
- School of Medicine, The University of Notre Dame, Fremantle, Australia
| | | | | | | | - MyNgan Duong
- Advara Heart Care, Leabrook, Adelaide, Australia
| | - Leighton Kearney
- Advara Heart Care, Leabrook, Adelaide, Australia
- Cardiology, Warringal Private Hospital, Heidelberg, Victoria, Australia
| | - Simon Stewart
- Institute for Health Research, The University of Notre Dame, Fremantle, Australia
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, United Kingdom
| | - Geoff Strange
- School of Medicine, The University of Notre Dame, Fremantle, Australia
- Heart Research Institute, Sydney, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
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Shelbaya K, Claggett B, Dorbala P, Skali H, Solomon SD, Matsushita K, Konety S, Mosley TH, Shah AM. Stages of Valvular Heart Disease Among Older Adults in the Community: The Atherosclerosis Risk in Communities Study. Circulation 2023; 147:638-649. [PMID: 36524478 PMCID: PMC9974863 DOI: 10.1161/circulationaha.122.061396] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 11/03/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Limited data exist on American College of Cardiology/American Heart Association valvular heart disease (VHD) stage prevalence, progression, and association with incident cardiovascular diseases in late life. METHODS Participants in the ARIC study (Atherosclerosis Risk in Communities), a prospective community-based cohort study, underwent protocol echocardiography at ARIC visits 5 (2011-2013) and 7 (2018-2019), and their aortic stenosis, aortic regurgitation, mitral stenosis, and mitral regurgitation stage were defined according to American College of Cardiology/American Heart Association guidelines. The overall VHD stage prevalence at visit 5 was measured. The associations between VHD stages and incident adjudicated death, heart failure, coronary heart disease, stroke, and atrial fibrillation were assessed with Cox proportional hazard models adjusted for age, sex, race, hypertension, diabetes, prior myocardial infarction, heart failure, body mass index, study center, systolic blood pressure, estimated glomerular filtration rate, and low-density lipoprotein at visit 5. Longitudinal changes in VHD stage prevalence over ≈6 years were estimated with inverse probability of attrition weights to account for participant attrition. RESULTS Among 6118 ARIC participants, the mean±SD age was 76±5 years, 42% were male, and 22% reported Black race. Stage A VHD was present in 39%, stage B in 17%, and stage C/D in 1.1%;, 0.7% had previously undergone valve replacement or repair. A graded association was observed between stage A, B, and C/D VHD and risk of all-cause mortality, incident heart failure, incident atrial fibrillation, and incident coronary heart disease, but not incident stroke. Similar findings were observed for stages of each valvular lesion individually. During the 6.6 years (interquartile range, 6.1-7.0 years) between visits 5 and 7 (mean age, 81±4 years), the prevalence of freedom from VHD stage decreased from 43% to 24%, whereas the prevalence of stage C/D VHD increased from 1% to 7%. CONCLUSIONS Subclinical VHD is common in older adults, with 39% at risk (stage A) and 17% with progressive VHD (stage B), and is independently associated with risk of incident cardiovascular events. VHD stages progress over 6 years in late life, with a several-fold increase in prevalence of severe VHD (stage C/D), highlighting the public health importance of interventions to mitigate VHD progression.
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Haseeb ul Rasool M, Saleem M, Nadeem M, Maqbool M, Aziz AA, Fox JM, Suleiman A. The Role of Transcatheter Aortic Valve Replacement in Asymptomatic Aortic Stenosis: A Feasibility Analysis. Cureus 2022; 14:e29522. [PMID: 36312695 PMCID: PMC9589522 DOI: 10.7759/cureus.29522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2022] [Indexed: 11/26/2022] Open
Abstract
Surgical aortic valve replacement (SAVR) is the current treatment of choice for good surgical candidates with moderate to severe symptomatic aortic stenosis (AS). As transcatheter aortic valvular replacement (TAVR) has shown an improved one and two-year all-cause mortality, it has been chosen for moderately symptomatic severe AS patients. The purpose of this review was to perform a clinical comparison of TAVR vs. SAVR and to analyze the Health Index Factor (HIF) that makes TAVR a treatment of choice in asymptomatic AS patients. An extensive literature search of PubMed, Cochrane, and Embase databases was performed using the keywords “Aortic stenosis”, “SAVR”, “TAVR”, and “Asymptomatic”. A total of 45 prospective randomized clinical trials in the English language that were published from the year 2000 onwards were included in the final analysis. It has been found that 59.3% of asymptomatic AS patients are likely to die in the next five years without proactive treatment. Multiple studies have proven that early intervention with aortic valve replacement is superior to conservative treatment in severe asymptomatic AS; however, the choice between SAVR and TAVR is not well established. The NOTION Trial, SURTAVI Trail, and PARTNER 3 study have shown the non-inferiority of TAVR over SAVR, during one-year follow-up for low surgical risk patients. Evolut Low-Risk study and Early TAVR are the only two prospective studies performed to date that have enrolled patients with asymptomatic severe AS. The Evolut Trial demonstrated no difference in all-cause mortality at 30 days (1.3% vs. 4.8%. p=0.23), and 12 days (1.3% vs. 6.5%, p=0.11). Additionally, TAVR also decreases the risk of post-procedural atrial fibrillation, acute kidney injury (AKI), and rehospitalization, and leads to significant improvement in the mean trans-aortic pressure gradient. TAVR also showed marked improvement in the 30-day Quality of Life (QOL) index, where SAVR did not report any significant change in the QOL index. However, the official recommendations of Early TAVR are still awaited. TAVR has consistently shown a statistically non-significant difference in case mortality, risk of stroke, and rehospitalization with moderate to high surgical risk patients whereby recent initial trials have shown significant improvement in the QOL index and hemodynamic index for patients with asymptomatic disease. More extensive studies are required to prove the risk stratifications, long-term outcomes, and clinical characteristics that would make TAVR a preferred intervention in asymptomatic patients.
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11
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Stewart S, Afoakwah C, Chan YK, Strom JB, Playford D, Strange GA. Counting the cost of premature mortality with progressively worse aortic stenosis in Australia: a clinical cohort study. THE LANCET. HEALTHY LONGEVITY 2022; 3:e599-e606. [PMID: 36102774 PMCID: PMC9484033 DOI: 10.1016/s2666-7568(22)00168-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 06/26/2022] [Accepted: 06/28/2022] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Aortic stenosis is the most common cardiac valve disorder requiring clinical management. However, there is little evidence on the societal cost of progressive aortic stenosis. We sought to quantify the societal burden of premature mortality associated with progressively worse aortic stenosis. METHODS In this observational clinical cohort study, we examined echocardiograms on native aortic valves of 98 565 men and 99 357 women aged 65 years or older across 23 sites in Australia, from Jan 1, 2003, to Dec 31, 2017. Individuals were grouped according to their peak aortic valve velocity in 0·50 m/s increments up to 4·00 m/s or more (severe aortic stenosis), using 1·00-1·99 m/s (no aortic stenosis) as the reference group. Sex-specific premature mortality and years of life lost during a 5-year follow-up were calculated, along with willingness-to-pay to regain quality-adjusted life years (QALYs). FINDINGS Overall, 20 701 (21·0%) men and 18 576 (18·7%) women had evidence of mild-to-severe aortic stenosis. The actual 5-year mortality in men with normal aortic valves was 32·1% and in women was 26·1%, increasing to 40·9% (mild aortic stenosis) and 52·2% (severe aortic stenosis) in men and to 35·9% (mild aortic stenosis) and 55·3% (severe aortic stenosis) in women. Overall, the estimated societal cost of premature mortality associated with aortic stenosis was AU$629 million in men and $735 million in women. Per 1000 men and women investigated, aortic stenosis was associated with eight more premature deaths in men resulting in 32·5 more QALYs lost (societal cost of $1·40 million) and 12 more premature deaths in women resulting in 57·5 more QALYs lost (societal cost of $2·48 million) when compared with those without aortic stenosis. INTERPRETATION Any degree of aortic stenosis in older individuals is associated with premature mortality and QALYs. In this context, there is a crucial need for cost-effective strategies to promptly detect and optimally manage this common condition within our ageing populations. FUNDING Edwards LifeSciences, National Health and Medical Research Council of Australia, and the National Heart, Lung, and Blood Institute.
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Affiliation(s)
- Simon Stewart
- Institute for Health Research, University of Notre Dame Australia, Fremantle, WA, Australia; School of Medicine, Dentistry & Nursing, University of Glasgow, Glasgow, UK; Menzies Health Institute Queensland, Griffith University, Gold Coast, QLD, Australia
| | - Clifford Afoakwah
- Centre for Applied Health Economics, Griffith University, Brisbane, QLD, Australia; Menzies Health Institute Queensland, Griffith University, Gold Coast, QLD, Australia; Torrens University Australia, Adelaide, SA, Australia
| | - Yih-Kai Chan
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, Australia
| | - Jordan B Strom
- Richard A And Susan F Smith Centre for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Centre, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - David Playford
- Institute for Health Research, University of Notre Dame Australia, Fremantle, WA, Australia
| | - Geoffrey A Strange
- Institute for Health Research, University of Notre Dame Australia, Fremantle, WA, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
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Herrmann HC, Pibarot P, Wu C, Hahn RT, Tang GHL, Abbas AE, Playford D, Ruel M, Jilaihawi H, Sathananthan J, Wood DA, De Paulis R, Bax JJ, Rodes-Cabau J, Cameron DE, Chen T, Del Nido PJ, Dweck MR, Kaneko T, Latib A, Moat N, Modine T, Popma JJ, Raben J, Smith RL, Tchetche D, Thomas MR, Vincent F, Yoganathan A, Zuckerman B, Mack MJ, Leon MB. Bioprosthetic Aortic Valve Hemodynamics: Definitions, Outcomes, and Evidence Gaps: JACC State-of-the-Art Review. J Am Coll Cardiol 2022; 80:527-544. [PMID: 35902177 DOI: 10.1016/j.jacc.2022.06.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 05/19/2022] [Accepted: 06/01/2022] [Indexed: 12/23/2022]
Abstract
A virtual workshop was organized by the Heart Valve Collaboratory to identify areas of expert consensus, areas of disagreement, and evidence gaps related to bioprosthetic aortic valve hemodynamics. Impaired functional performance of bioprosthetic aortic valve replacement is associated with adverse patient outcomes; however, this assessment is complicated by the lack of standardization for labelling, definitions, and measurement techniques, both after surgical and transcatheter valve replacement. Echocardiography remains the standard assessment methodology because of its ease of performance, widespread availability, ability to do serial measurements over time, and correlation with outcomes. Management of a high gradient after replacement requires integration of the patient's clinical status, physical examination, and multimodality imaging in addition to shared patient decisions regarding treatment options. Future priorities that are underway include efforts to standardize prosthesis sizing and labelling for both surgical and transcatheter valves as well as trials to characterize the consequences of adverse hemodynamics.
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Affiliation(s)
- Howard C Herrmann
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Philippe Pibarot
- Department of Medicine, Québec Heart and Lung Institute, Laval University, Québec City, Quebec, Canada
| | - Changfu Wu
- U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Rebecca T Hahn
- Columbia University Medical Center, New York, New York, USA
| | | | - Amr E Abbas
- Beaumont Hospital Royal Oak, Royal Oak, Michigan, USA
| | - David Playford
- The University of Notre Dame, Fremantle, Western Australia, Australia
| | - Marc Ruel
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Hasan Jilaihawi
- Heart Valve Center, NYU Langone Health, New York, New York, USA
| | - Janarthanan Sathananthan
- Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - David A Wood
- Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Jeroen J Bax
- Leiden University Medical Centre, Leiden, the Netherlands
| | - Josep Rodes-Cabau
- Department of Medicine, Québec Heart and Lung Institute, Laval University, Québec City, Quebec, Canada
| | - Duke E Cameron
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Tiffany Chen
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Pedro J Del Nido
- Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Marc R Dweck
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Tsuyoshi Kaneko
- Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Azeem Latib
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Neil Moat
- Abbott Structural Heart, Santa Clara, California, USA
| | - Thomas Modine
- Hopital Cardiologique de Haut Leveque, Bordeaux, France
| | | | - Jamie Raben
- U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Robert L Smith
- Baylor Scott and White, The Heart Hospital, Plano, Texas, USA
| | | | | | | | - Ajit Yoganathan
- Georgia Institute of Technology and Emory University, Atlanta, Georgia, USA
| | - Bram Zuckerman
- U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Michael J Mack
- Baylor Scott and White, The Heart Hospital, Plano, Texas, USA
| | - Martin B Leon
- Columbia University Medical Center, New York, New York, USA
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Kardos A, Rusinaru D, Maréchaux S, Alskaf E, Prendergast B, Tribouilloy C. Implementation of a CT-derived correction factor to refine the measurement of aortic valve area and stroke volume using Doppler echocardiography improves grading of severity and prediction of prognosis in patients with severe aortic stenosis. Int J Cardiol 2022; 363:129-137. [PMID: 35716947 DOI: 10.1016/j.ijcard.2022.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 06/07/2022] [Accepted: 06/10/2022] [Indexed: 11/26/2022]
Abstract
AIMS To assess rates of reclassification of severity and associated 5-year survival in patients with severe aortic stenosis (AS) and preserved left ventricular ejection fraction (LVEF) after application of a CT-derived correction factor (CF) to refine the measurement of aortic valve area (AVA) and stroke volume index (SVi) using Doppler echocardiography. METHODS AND RESULTS We enrolled 1450 patients with severe AS and preserved LVEF from a French registry. Multiplication of echocardiographic LV outflow tract diameter by a CT-derived CF of 1.13 to calculate the AVA and SVi using the continuity equation resulted in reclassification of 39% of patients from severe to moderate AS (AVA > 1 cm2) and 77% from low flow (LF, SVi < 35 ml/m2) to normal flow (NF, SVi ≥ 35 ml/m2). After application of the CF, 5-year survival with conservative management was 50 ± 4% for severe AS compared to 62 ± 4% for moderate AS (p < 0.001). A strategy of medical management followed by intervention for severe AS was associated with higher risk of mortality over 5-year follow-up after adjustment for covariates and application of the CF (HR 1.35 [1.10-1.55], p = 0.015). Five-year survival was also poorer in patients remaining in the LF group after application of the CF, even after valve intervention (72%, 66% and 47% for NF to NF, LF to NF and LF to LF, respectively). After adjustment for covariates (including intervention), risk of mortality was higher in LF to LF patients compared to NF to NF (HR 1.78 [1.25-2.56]), but similar for NF to NF and LF to NF (HR 1.20 [0.90-1.60]). CONCLUSION Refined accuracy of echocardiographic LV outflow tract diameter measurement using a CF of 1.13 before derivation of AVA and SVi in patients with severe AS and preserved LVEF allows improved grading of severity, and prediction of prognosis. We recommend implementation of the CF during routine echocardiography when using the continuity equation for Doppler haemodynamic measurements.
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Affiliation(s)
- Attila Kardos
- Translational Cardiovascular Research Group, Department of Cardiology, Milton Keynes University Hospital, United Kingdom; Faculty of Medicine and Health Sciences, University of Buckingham, Buckingham, United Kingdom,.
| | - Dan Rusinaru
- Pôle Coeur-Thorax-Vaisseaux, Department of Cardiology, University Hospital Amiens, Amiens, France; UR UPJV 7517, Jules Verne University of Picardie, Amiens, France; Translational Cardiovascular Research Group, Department of Cardiology, Milton Keynes University Hospital, United Kingdom
| | - Sylvestre Maréchaux
- Centre Universitaire de Recherche en Santé, Laboratoire MP3CV -, EA 7517, Université de Picardie, Amiens, France
| | - Ebraham Alskaf
- School of Biomedical Engineering & Imaging Sciences, King's College London, London, United Kingdom
| | - Bernard Prendergast
- Department of Cardiology, St Thomas' Hospital and Cleveland Clinic London, United Kingdom
| | - Christophe Tribouilloy
- Pôle Coeur-Thorax-Vaisseaux, Department of Cardiology, University Hospital Amiens, Amiens, France; UR UPJV 7517, Jules Verne University of Picardie, Amiens, France
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