Predictors of coronary and carotid atherosclerosis in patients with severe degenerative aortic stenosis

Differences between proximal and distal M1 occlusions after mechanical thrombectomy

PURPOSE

Whether M1 occlusions proximal (pM1) and distal (dM1) to the lenticulostriate perforators result in different clinical outcomes after mechanical thrombectomy (MT) is unknown. We retrospectively compared the clinical outcomes and baseline characteristics of patients with these two types of occlusions.

METHODS

From March 2010 to May 2019, we performed MT for 141 M1 occlusions, including pM1 occlusions (n = 58) and dM1 occlusions (n = 83).

RESULTS

Good clinical outcomes (modified Rankin Scale score 0 to 2) were achieved in 28 out of 58 (48.3%) patients with pM1 occlusions and 46 out of 83 (55.4%) patients with dM1 occlusions without significance (p = 0.493). Cardioembolic occlusions represented 19 out of 58 (32.6%) pM1 occlusions and 53 out of 83 (63.9%) dM1 occlusions, and atherosclerotic occlusions represented 37 out of 58 (63.8%) pM1 occlusions and 27 out of 83 (32.5%) dM1 occlusions, with significance (p = 0.001). Rescue treatments, such as balloon angioplasty or stenting, were needed more for pM1 occlusions than dM1 occlusions (21 out of 58 (36.2%) vs. 8 out of 83 (9.8%), p < 0.001). The multivariable logistic regression analysis demonstrated that the need for rescue treatment was associated with pM1 occlusions (adjusted odds ratio; 3.804, 95% confidence interval; 1.306-11.082, p = 0.014).

CONCLUSIONS

In our series, pM1 and dM1 occlusions did not significantly differ in good clinical outcomes. Our study also showed that pM1 occlusions were more strongly associated with atherosclerotic occlusions, while dM1 occlusions were more strongly associated with cardioembolic occlusions, and rescue treatments were needed more often for pM1 occlusions than dM1 occlusions.

Prevalence and Predictors of Atherosclerotic Peripheral Arterial Obstructive Disease in Severe Heart Valve Diseases

Despite witnessing an upsurge in heart valve diseases (HVDs), the correlation between HVDs and atherosclerotic peripheral arterial obstructive disease (PAOD) remains unclear. This study aims to investigate the prevalence and predictors of PAOD in HVDs.In this study, a total of 245 consecutive patients were examined: 153 with severe aortic valve stenosis (AS), 66 with severe primary mitral valve regurgitation (MR), and 26 with severe pure native aortic valve regurgitation (AR). All patients underwent ultrasound scan of the carotid artery to ascertain the presence of internal carotid artery stenosis (ICAS). ICAS was defined as a peak systolic velocity ≥ 125 cm/second and/or ≥ 50% reduction in diameter. In addition, we measured the ankle-brachial index in each leg using a volume plethysmograph. A result of ≤ 0.9 was considered lower extremity artery disease (LEAD).The presence of ICAS was statistically more frequent in patients with severe AS than in patients with severe MR and AR (11.1% versus 1.5% versus 3.8%; P = 0.038). LEAD was present in patients with severe AS (17.6%) and MR (10.6%) but not in patients with severe AR (P = 0.037). The multivariate analysis revealed that the presence of severe AS (OR, 5.6 [1.3-24.9]; P = 0.023) was an independent predictor for ICAS, while history of coronary artery disease (OR, 4.8 [2.2-10.5]; P < 0.001) was an independent predictor for LEAD.The prevalence of PAOD varies depending on each valvular disease. Individual screening should be considered on the basis of atherosclerotic risk factors, especially for patients with severe AS.

Coronary artery disease is associated with valvular heart disease, but could it Be a predictive factor?

OBJECTIVE

This study was conducted to evaluate the prevalence of significant coronary artery disease (CAD) in patients with severe valvular heart disease (VHD) and the association between these two cardiac entities. Our research aims to introduce the theory of a possible causal relationship.

METHODS

A retrospective study was conducted on 1308 consecutive patients who underwent surgery for severe VHD in the cardiovascular department of Notre-Dame de Secours University Hospital (NDSUH) between December 2000 and December 2016. According to transthoracic echocardiography, patients were divided into 4 groups: patients with severe aortic stenosis (AS), patients with severe aortic regurgitation (AR), patients with severe mitral stenosis (MS), and patients with severe mitral regurgitation (MR). Preoperative coronary angiographies were reviewed for the presence or the absence of significant CAD (≥50% luminal stenosis). Chi-square test and 2 × 2 tables were used.

RESULTS

Of the 1308 patients with severe VHD, 1002 patients had isolated aortic valve disease, 240 patients had isolated mitral valve disease, and 66 patients had combined aortomitral valve disease. CAD was detected in 27.75% of all patients with severe VHD, in 32% of patients with isolated aortic valve disease, and in 15% of patients with isolated mitral valve disease. Statistical analysis showed a higher prevalence in patients with severe aortic valve stenosis and a significant relationship between CAD and aortic valve disease, mainly severe AS (p < 0.0001).

CONCLUSION

The prevalence of CAD in patients with VHD is 27.75%, and it correlates significantly with aortic valve disease, in particular with severe AS. Future large studies are needed to evaluate the possible causal relationship.

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

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

Sex, Race, and Socioeconomic Disparities in Patients With Aortic Stenosis (from a Nationwide Inpatient Sample)

Aortic stenosis (AS) is the third most prevalent cardiovascular disease following hypertension and coronary artery disease. The primary objective of this cross-sectional study is to examine gender, racial, and socioeconomic disparities in AS-related health care utilization in patients aged ≥50 years using data from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample. AS was identified among inpatient discharges with International Classification of Diseases, Ninth Revision, Clinical Modification, code 424.1. Using stratum-specific weighted totals, means, proportions, and regression models, we examined time trends and disparities for inhospital AS prevalence according to gender, race, and income over the 2002 to 2012 period, predictors of AS (gender, race, income, age, health insurance, co-morbidities, and hospital-level characteristics), and AS's role as a predictor of inhospital death, length of stay, and total charges. Inhospital AS prevalence increased from 2.10% in 2002 to 2.37% in 2012, with similar trends observed within gender, race, and income strata. Women were less likely to have AS compared with men (adjusted odds ratio [ORadj] 0.84; 95% confidence interval [CI] 0.83 to 0.86). Blacks (ORadj 0.68; 95% CI 0.66 to 0.71), Hispanics (ORadj 0.79; 95% CI 0.76 to 0.84), and Asians/Pacific Islanders (ORadj 0.68; 95% CI 0.64 to 0.74) were less likely than whites to have AS diagnosis that was directly associated with income. AS was inversely related to inhospital death but positively linked to total charges overall and longer hospital stays among men, whites, and middle-income patients. However, shorter stays with AS were observed among blacks. In conclusion, among older inpatients, AS prevalence was ∼2% and was higher among males, whites, and higher income groups. Although inhospital death was lower and total charges were higher in AS, length of stay's association with AS varied by gender, race, and income.

The coexistence of carotid and lower extremity atherosclerosis further increases cardio-cerebrovascular risk in type 2 diabetes

Background

Both carotid and lower limb atherosclerosis are associated with increased cardiovascular and cerebrovascular risks. However, it is still unclear whether the concomitant presence of carotid and lower extremity atherosclerosis further increases the cardiovascular and cerebrovascular risks. Therefore, our aim is to investigate whether the coexistence of carotid and lower extremity atherosclerosis was associated with higher cardiovascular and cerebrovascular risks in patients with type 2 diabetes.

Methods

This cross-sectional study was performed in 2830 hospitalized patients with type 2 diabetes. Based on carotid and lower limb Doppler ultrasound results, the patients were divided into three groups including 711 subjects without atherosclerosis, 999 subjects with either carotid or lower limb atherosclerosis, and 1120 subjects with both carotid and lower limb atherosclerosis. And we compared the clinical characteristics and prevalence of both cardio-cerebrovascular events (CCBVEs) and self-reported cardio- cerebrovascular diseases (CCBVDs) among the three groups.

Results

After adjusting for age, sex, and duration of diabetes, there were significant increases in the prevalence of both CCBVEs (3.8 vs. 11.8 vs. 26.4 %, p < 0.001 for trend) and self-reported CCBVDs (6.9 vs. 19.9 vs. 36.5 %, p < 0.001 for trend) across the three groups (diabetics without atherosclerosis, diabetics with either carotid or lower limb atherosclerosis, and diabetics with both carotid and lower extremity atherosclerosis). A fully adjusted logistic regression analysis also revealed that compared with those without atherosclerosis, those with either carotid or lower limb atherosclerosis had higher risk of CCBVEs (OR 1.724, 95 % CI 1.001–2.966) and self-reported CCBVDs (OR 1.705, 95 % CI 1.115–2.605), and those with concomitant presence of carotid and lower extremity atherosclerosis had the highest risk of CCBVEs (OR 2.869, 95 % CI 1.660–4.960) and self-reported CCBVDs (2.147, 95 % CI 1.388–3.320)(p < 0.001 for trend in CCBVEs and p = 0.002 for trend in CCBVDs, respectively).

Conclusions

Either carotid or lower limb atherosclerosis was obviously related to increased cardio-cerebrovascular risk in type 2 diabetes. The concomitant presence of carotid and lower extremity atherosclerosis further increased cardio-cerebrovascular risk in patients with type 2 diabetes. The combined application of carotid and lower extremity ultrasonography may help identify type 2 diabetics with higher cardio-cerebrovascular risk.

A Preoperative Assessment of Significant Coronary Stenosis Based on a Semiquantitative Analysis of Coronary Artery Calcification on Noncontrast Computed Tomography in Aortic Stenosis Patients Undergoing Aortic Valve Replacement

Invasive coronary angiography (ICA) is the recommended assessment for coronary artery disease in patients undergoing elective aortic valve replacement (AVR). Noncontrast computed tomography (CT) is useful for evaluating lung lesions and calcifications at the cannulation site of the ascending aorta. The purpose of this study was to evaluate the role of noncontrast CT in the visual assessment of coronary artery calcification (CAC) in patients undergoing AVR. We retrospectively identified patients with significant aortic stenosis (AS) who were referred for AVR between January 2006 and December 2013. Among these, we included 386 patients (53.6% males, 69.2 ± 8.4 years) who underwent both noncontrast CT and ICA. Significant coronary artery stenosis (CAS) in the ICA was defined as luminal stenosis ≥70%. The 4 main coronary arteries were visually assessed on noncontrast CT and were scored based on the Weston score as follows: 0, no visually detected calcium; 1, a single high-density pixel detected; 3, calcium was dense enough to create a blooming artifact; and 2, calcium in between 1 and 3. Four groups were reclassified by the sum of the Weston scores from each vessel, as follows: noncalcification (0); mild calcification (1-4); moderate calcification (5-8); and severe calcification (9-12). Receiver-operating characteristic (ROC) analysis was generated to identify the cutoff Weston score values for predicting significant CAS. Diagnostic estimates were calculated based on these cutoffs. In the ICA analysis, 62 of the 386 patients (16.1%) had significant CAS. All patients were divided into 4 groups. The noncalcification group had 97 subjects (Weston score 0), the mild degree group had 100 (2.6 ± 1.0), the moderate calcification group had 114 (6.6 ± 1.1), and the severe calcification group had 75 (10.7 ± 1.1). The prevalence of significant CAS in the noncalcification, mild, moderate, and severe groups was 1% (1/97), 5% (5/100), 24% (27/114), and 39% (29/75), respectively. The group with CAS had significantly more CAC than the group without CAS (8.37 ± 2.93 vs 4.01 ± 3.75, P < 0.001). The cutoff value (by Weston score) for predicting significant CAS is ≥5 (sensitivity 90.3%, specificity 59.0%, positive predictive value 29.6%, and negative predictive value 97%). The degree of CAC detected on noncontrast CT can help to predict significant CAS in AS patients who are referred for AVR. For the clinicians, the visual assessment of CAC on noncontrast CT was easy and useful for estimating CAS. Therefore, ICA should be recommended to selective patients based on patients' CAC and Weston scores during the preoperative evaluation for elective AVR.

Depressed Systemic Arterial Compliance is Associated with the Severity of Heart Failure Symptoms in Moderate-to-Severe Aortic Stenosis: a Cross-Sectional Retrospective Study

BACKGROUND

Patients with aortic stenosis (AS) may develop heart failure even in the absence of severe valve stenosis. Our aim was to assess the contribution of systemic arterial properties and the global left ventricular afterload to graded heart failure symptoms in AS.

METHODS

We retrospectively reviewed medical records of 157 consecutive subjects (mean age, 71±10 years; 79 women and 78 men) hospitalized owing to moderate-to-severe degenerative AS. Exclusion criteria included more than mild aortic insufficiency or disease of another valve, atrial fibrillation, coronary artery disease, severe respiratory disease or anemia. Heart failure symptoms were graded by NYHA class at admission. Systemic arterial compliance (SAC) and valvulo-arterial impedance (Zva) were derived from routine echocardiography and blood pressure.

RESULTS

Sixty-one patients were asymptomatic, 49 presented mild (NYHA II) and 47 moderate-to-severe (NYHA III-IV) heart failure symptoms. Mild symptoms were associated with lower SAC and transvalvular gradients, while more severe exercise intolerance coincided with older age, lower systolic blood pressure, smaller aortic valve area and depressed ejection fraction. By multiple ordinal logistic regression, the severity of heart failure symptoms was related to older age, depressed ejection fraction and lower SAC. Each decrease in SAC by 0.1 ml/m² per mmHg was associated with an increased adjusted odds ratio (OR) of a patient being in one higher category of heart failure symptoms graded as no symptoms, mild exercise intolerance and advanced exercise intolerance (OR: 1.16 [95% CI, 1.01-1.35], P=0.045).

CONCLUSIONS

Depressed SAC may enhance exercise intolerance irrespective of stenosis severity or left ventricular systolic function in moderate-to-severe AS. This finding supports the importance of non-valvular factors for symptomatic status in AS.