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With an ageing population and improved diagnostic modalities, the number of patients with valvular heart disease is dramatically increasing. Considering projected changes in the age distribution, a further accentuation of this trend can be expected and this may indeed be considered “the next cardiac epidemic”.1 Obviously, we are faced with more complex decisions in patients with advanced age and increasing comorbidities. Advances in percutaneous valve interventional techniques have entered into routine practice. At the same time, new data on the natural history of disease and the identification of predictors of outcome permit improvement in the decision-making process and management of patients with valvular heart disease.
In a population-based study which followed up 953 subjects for 10 years, a high prevalence of calcific aortic valve disease (28%) associated with long-term exposure to raised cholesterol levels and active smoking was described.2 Intraleaflet haemorrhage (detected by immunohistochemistry at the moment of aortic valve replacement surgery) was frequently present in the valve leaflets of degenerative aortic stenosis (AS) and was associated with rapid progression of AS.3 In a small study of 164 patients with rheumatic AS (of whom 30 were treated with a statin), progression of AS was slower in patients receiving statins than in untreated patients (annual change of peak aortic velocity: 0.05±0.07 m/s/year vs 0.12±0.11 m/s/year, p=0.001).4 On the other hand in the ASTRONOMER trial, a randomised double-blind study, that allocated 269 patients to rosuvastatin 40 mg daily or to placebo, statin treatment did not reduce progression of the disease in patients with AS.5
Predictors of outcome
Based on the aortic jet velocity and the B-type natriuretic peptide (BNP) level, a risk score predicting outcome in patients with moderate-to-severe asymptomatic AS was derived and validated in an independent cohort: score=(peak velocity (m/s) × 2)+(ln of BNP × 1.5)+1.5 (if female sex). Event-free survival after …