Prevalence of comorbidities and associated cardiac diseases in patients with valve aortic stenosis. Potential implications for the decision-making process

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Abstract

Objectives

Aortic valve replacement (AVR) is recommended in patients with symptomatic aortic stenosis (AS). However a large number of elderly patients remain untreated because of a high operative risk. The aim of this study was to assess the risk profile of a group of AS patients, evaluating the prevalence of comorbidities and associated cardiac diseases and their impact on therapeutic decisions.

Methods

Two-hundred forty consecutive AS patients underwent complete clinical evaluation, in order to define the stenosis severity, the prevalence of several associated cardiac conditions and comorbidities. Furthermore, the treatment choices based on this approach were recorded.

Results

Mean age was 78.6 ± 8.93 years, 75.5% was ≥ 75 years old, 60% females; 226 patients (94.2%) had symptoms and 54.2% was in NYHA classes III–IV. Valve area < 1 cm2 was detected in 81.6% of patients. Both comorbidities and associated cardiac diseases were common; particularly, renal dysfunction was detected by estimated glomerular filtration rate in 52.7%, chronic obstructive lung disease in 25.4%, cerebrovascular/peripheral artery disease in 30.8% and 11.6%, respectively, diabetes in 30%, malignancies (current or previous) in 26.6% of patients. Among associated cardiac diseases, coronary artery disease was detected in 43.7%, LV systolic dysfunction in 28.7%, pulmonary hypertension in 67%, at least moderate mitral regurgitation in 32.5% and porcelain aorta in 7.5% of patients. Fourteen asymptomatic patients (pts) (5.9%) remained in follow-up, 77 (32%) underwent surgical AVR, 64 (26.7%) underwent transcatheter valve implantation, 28 (11.6%) underwent balloon valvuloplasty and 57 (23.8%), despite symptoms, remained on medical therapy alone.

Conclusions

Comorbidities and coexisting cardiac diseases are very common in AS and may strongly influence the decision-making process.

Introduction

Aortic valve stenosis (AS) is the most common heart valve disease in western countries and its prevalence steadily increases with age [1], [2]. Given the poor outcome of AS when symptoms develop [3], [4], current guidelines recommend aortic valve replacement (AVR) in patients (pts) with severe, symptomatic AS [5], [6]. Recently, along with surgical replacement, transcatheter AVR through aortic bioprosthesis implantation has been proposed [7]. However, a large number of pts with severe AS, especially the elderly, are denied AVR and still remain untreated [8] because of a high risk of perioperative mortality, as evaluated by several risk score algorithms (EuroSCORE, STS and Parsonnet score) based on individual preoperative cardiac and noncardiac status [9], [10]. As a matter of fact, several comorbidities and concomitant cardiac diseases may contribute to prognosis of hemodynamically significant AS [11], [12], [13]. To our knowledge, the few published data regarding the cardiac and extracardiac conditions associated with AS are focused on specific clinical features and selected group of pts [13], [14], [15], [16], [17]. Accordingly, the aim of the present study was to assess the “global” risk profile of a group of consecutive pts with AS, focusing on the prevalence of comorbidities and coexisting cardiac diseases and their relevance in decision-making process.

Section snippets

Methods

The study population consists of 240 consecutive pts with aortic valve stenosis admitted to our Cardiology Division for clinical–instrumental evaluation over a 12-month period. At the admission, all pts underwent detailed clinical history, physical examination, blood sample, electrocardiogram, chest radiogram, and Doppler-echocardiogram. All other instrumental examinations for the assessment of major comorbidities and associated cardiac diseases were also made as needed (see below). Written

Results

Demographic and clinical characteristics of pts included in this study are summarized in Table 1. Mean age was over 78 years and one fourth of pts was older than 85 years, while only 19 pts (7.9%) were younger than 65 years. According to the body mass index (BMI) > 30 kg/m2, 10% of pts were obese. At the admission 226 pts (94.2%) were symptomatic for at least one of the typical manifestations (dyspnoea, angina and/or syncope). More than one half of the whole population was in New York Heart

Discussion

The main finding of our study – in which a systematic diagnostic work-up on a large group of adult and elderly pts with AS was performed – was the identification of a relevant prevalence of several comorbidities and/or associated cardiac conditions, with potential therapeutic and prognostic implications. These results allow several comments.

First of all, the high prevalence of older subjects with AS in our study population and the frequent association of valve stenosis with coronary and

Conclusion

In adult and elderly subjects with valve AS, a careful search for comorbidities and associated cardiac conditions through a systematic diagnostic approach appears to be relevant for an accurate risk stratification and the choice of adequate therapeutic strategies. Further data are needed to define the prognostic relevance of this approach.

Acknowledgement

The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [33].

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