Characterisation of patients with concomitant cancer in significant aortic stenosis

Background

There is an increasing incidence of cancer worldwide, while aortic stenosis is the most common valvular heart disease. However, management of aortic stenosis (AS) in patients with cancer remains poorly understood. The presence of concomitant AS in patients with cancer may confer added morbidity and mortality.

Methods

We studied 727 consecutive patients with index echocardiographic diagnosis of moderate to severe aortic stenosis (aortic valve area <1.5cm2). These patients were divided in patients with or without concomitant cancer. Baseline clinical and echocardiographic parameters were compared by appropriate univariate analyses. Kaplan-Meier curves were constructed to compare mortality, admissions for congestive cardiac failure and aortic valve replacement between the groups.

Results

Eighty-five (11.7%) patients had concomitant cancer with moderate to severe AS. Of those, 45 (52.9%) had active cancer. The group with cancer was similar in terms of age, body mass index, clinical comorbidities compared to the group without cancer. AS severity and echocardiographic profile was similar except for a lower LVIDd (43.6±12.0 vs 47.4±8.9mm, p<0.001), and LV mass index (103.1±43.2 vs 116.6±41.5, p=0.005). There was higher mortality in the cancer group (log-rank 17.6, p<0.001), similar incidence of admissions for cardiac failure (log-rank 0.58, p=0.446) and a lower incidence of aortic valve replacement (log-rank 3.96, p=0.047) compared to the group without cancer. Patients with AS who received cancer treatment did better than those that did not receive cancer treatment.

Conclusion

Concomitant cancer in patients with moderate to severe AS was associated with increased mortality, and a lower incidence of aortic valve replacement. Further studies are warranted to investigate the role of valve replacement in patients with cancer.

Figure 1

Funding Acknowledgement

Type of funding source: None

Co-existing aortic regurgitation associated with adverse clinical outcomes in patients with moderate to severe aortic stenosis

Background

Aortic regurgitation (AR) is a common comorbidity in patients with aortic stenosis (AS), but co-existing AR has often been an exclusion criterion from major clinical trials. The impact of co-existing AR on the natural history of AS has not been well-described.

Purpose

We compared clinical outcomes in patients with moderate to severe AS with or without co-existing AR.

Methods

Consecutive patients (n=1188) with index echocardiographic diagnosis of moderate to severe AS (AVA <1.5cm2) were studied. They were divided into those with co-existing AR (at least moderate severity) and those without. Adverse composite clinical outcomes were defined as either mortality or admissions for congestive cardiac failure on subsequent follow-up for at least five years. Appropriate univariate and multivariable analyses were employed to compare the two groups.

Results

There were 88 patients (7.4%) with co-existing AR and AS. These patients did not differ significantly in age, but had lower body mass index (22.9±3.8 vs 25.3±5.1 kg/m2). They also had lower diastolic blood pressure (68.7±10.7 vs 72.2±12.3 mmHg), larger end-diastolic volume index (68.8±18.8 vs 60.4±17.8 ml/m2) and left ventricular mass index (118.6±36.4 vs 108.9±33.1 g/m2). The prevalence of cardiovascular risk factors did not differ significantly between the groups. Co-existing AR was associated with adverse outcomes (log-rank 4.20, p=0.040). On multivariable Cox-regression, co-existing AR remained independently associated with adverse outcomes (hazard ratio 1.51, 95% CI 1.13–2.02) after adjusting for age, AS severity and left ventricular ejection fraction.

Conclusion

In patients with AS, co-existing AR was associated with a distinct echocardiographic profile and adverse outcomes.

Funding Acknowledgement

Type of funding source: None

Left-sided valvular heart disease associated with poor functional outcomes in patients with acute ischaemic stroke undergoing endovascular thrombectomy

Background

Valvular heart disease (VHD) may be an important comorbidity acute ischemic stroke (AIS), adversely affecting cerebral haemodynamics and consequently limiting functional recovery after endovascular thrombectomy (EVT). We examined the clinical profile and outcomes in patients with or without VHD who underwent EVT for AIS.

Methods

Consecutive patients (n=224) who underwent EVT for AIS were examined. All patients underwent transthoracic echocardiography within 6 months of AIS. The patients were divided into those with left-sided VHD (at least moderate severity of aortic valve or mitral valve stenosis or regurgitation) and those without. Univariate and multivariate analyses were employed to compare clinical profile and outcomes.

Results

There were 47 (20.9%) patients with VHD. Of these, 31 (66.0%) had mitral regurgitation, 15 (31.9%) had aortic stenosis, 8 (17.0%) had aortic regurgitation and 6 (12.8%) had mitral stenosis. VHD patients had a higher prevalence of atrial fibrillation (68.1% vs 43.5%, p=0.003) compared to those without, but stroke severity was similar. They had higher prevalence of pathological left ventricular (LV) remodelling, with larger end-diastolic volume index (77.9±34.5 vs 61.1±19.9ml/m2, p<0.001) and LV mass index (116.4±32.7 vs 99.8±32.2g/m2, p=0.002). Despite similar rates of recanalisation, VHD patients had poorer functional outcomes (mRS>2) at 3 months (68.1% vs 50.3%, p=0.029). On multivariable analyses, VHD remained independently associated with poor functional outcomes (adjusted OR 2.42, 95% CI 1.08–5.43), after adjusting for age, stroke severity and recanalisation rates.

Conclusion

VHD may be associated with poorer functional outcomes in patients with AIS undergoing EVT, despite similar rates of successful recanalisation.

Ordinal shift analyses

Funding Acknowledgement

Type of funding source: None

Clinical and echocardiographic outcomes of patients with moderate to severe aortic stenosis and preserved, mid-range and reduced ejection fraction

Background

Left ventricular ejection fraction (EF) plays an important role in risk stratifying and guiding therapy for patients with aortic stenosis (AS). This study aims to describe the clinical and echocardiographic outcomes of AS patients with preserved (ASpEF), mid-range (ASmrEF) and reduced (ASrEF) EF.

Methods

713 consecutive patients with index echocardiographic diagnosis of moderate-severe AS (aortic valve area <1.5cm2) were allocated according to the EF into three groups: ASrEF (EF<40%), ASmrEF (EF 40–50%), and ASpEF (EF>50%). The study outcomes were defined as 5-year all-cause mortality, heart failure admissions, and aortic valve replacement (AVR).

Results

In comparison to patients with ASpEF, those with ASrEF were more frequently male, and systolic blood pressure was significantly lower on enrolment (p<0.001). Diabetes, ischemic heart disease and atrial fibrillation were more commonly seen in the ASrEF and ASmrEF groups, compared to ASpEF group. All-cause mortality rates were 30.5% for ASpEF, 50.8% for ASmrEF, 55.0% for ASrEF groups (p<0.001). Increased rates of heart failure admissions were seen in the ASmrEF and ASrEF groups (30.5% and 33.9%, respectively, vs. 14.9% in ASpEF group). Patients with ASrEF had significantly higher rates of AVR as compared to those in the ASmrEF and ASpEF groups (p=0.032).

Conclusion

Echocardiographic and clinical outcomes of ASmrEF patients resembled those of ASrEF more closely than the ASpEF patients. Stratifying AS patients according to the different EF groups may improve risk assessment and treatment strategies.

Figure 1

Funding Acknowledgement

Type of funding source: None

Clinical course and outcome of primary acute angle-closure glaucoma in Singapore

PURPOSE

Data is lacking with regard to the factors which may predict the outcome of an acute glaucoma eye to treatment and its long-term prognosis. This study was carried out to identify such factors, in particular among Singaporeans.

METHODS

Fifty-seven eyes were included in this retrospective analysis and factors analysed included age and sex; the duration of onset of symptoms to the time they presented to hospital; state of pupil and presenting intraocular pressure (IOP); whether attack is terminated by medical treatment alone or a second procedure (eg laser, trabeculectomy) was required; final outcome with respect to the development of chronic angle closure glaucoma and state of pupil at last follow-up.

RESULTS

Patients with 24 to 72 hours' delay in presentation had a relative risk of 2.78 (CI = 1.03-7.46) in developing chronic glaucoma. Those who required the addition of a laser procedure to control the initial presenting IOP while those who proceeded to a trabeculectomy had relative risks of 3.63 (CI = 1.49-8.89) and 4.83 (CI = 1.18-19.7) respectively in developing chronic glaucoma when compared to patients who did not require any secondary treatment.

CONCLUSION

Delay in presentation, and unresponsiveness to medical treatment in termination of the acute attack in an acute angle closure glaucoma patient carry a significant risk of chronic glaucoma.