Natural history of aortic valve stenosis of varying severity in the elderly

doi:10.1016/S0002-9149(96)00235-4

The American Journal of Cardiology

Volume 78, Issue 1, 1 July 1996, Pages 97-101

https://doi.org/10.1016/S0002-9149(96)00235-4 Get rights and content

Abstract

To summarize, the presence of hemodynamically severe AS by Doppler echocardiography indicates a markedly increased risk for death within 4 years in persons aged 75 to 86 years. Moderate AS, too, may increase mortality in the elderly, whereas mild AS has a favorable outcome in the short term.

References (20)

AM Mitchell et al.
The clinical features of aortic stenosis
Am Heart J
(1954)
MA Chizner et al.
The natural history of aortic stenosis in adults
Am Heart J
(1980)
JH O' Keefe et al.
Natural history of candidates for balloon aortic valvuloplasty
E Rapaport
Natural history of aortic and mitral valve disease
Am J Cardiol
(1975)
TA Kelly et al.
Comparison of outcome of asymptomatic to symptomatic patients older than 20 years age with valvular aortic stenosis
Am J Cardiol
(1988)
KD Kennedy et al.
Natural history of moderate aortic stenosis
J Am Coll Cardiol
(1991)
M Lindroos et al.
Prevalence of aortic valve abnormalities in the elderly: an echocardiographic study of a random population sample
J Am Coll Cardiol
(1993)
M Lindroos et al.
Echocardiographic evidence of left ventricular hypertrophy in a general aged population
Am J Cardiol
(1994)
RB Devereux et al.
Echocardiographic assessment of left ventricular hypertrophy: comparison to necropsy findings
Am J Cardiol
(1986)
J Ross et al.
Aortic stenosis
Circulation
(1968)

There are more references available in the full text version of this article.

Cited by (148)

Bedside Physical Examination for the Diagnosis of Aortic Stenosis: A Systematic Review and Meta-analysis
2023, CJC Open
Patients with obstruction to the left ventricular outflow tract from degenerative aortic stenosis (AS) usually do not become symptomatic until their disease becomes graded as severe. We sought to assess the accuracy of the physical examination for the diagnosis of AS of at least moderate severity.
A systematic review and meta-analysis of case series and cohorts of patients who received a cardiovascular physical examination prior to receiving a left heart catheterization or an echocardiogram. PubMed, Ovid MEDLINE, the Cochrane Library, ClinicalTrials.gov, and Embase were searched with a date range from inception through December 10, 2021, without language restrictions.
Our systematic review yielded 7 observational studies with adequate data to perform a meta-analysis on 3 physical examination assessments. Auscultating a diminished second heart sound (likelihood ratio [LR] = 10.87, 95% confidence interval [CI], 3.94-30.12, P < 0.05) and palpating a delayed carotid upstroke (LR = 9.04, 95% CI, 3.12-25.44, P < 0.05) are useful for detecting AS of at least moderate severity. The absence of a systolic murmur radiating to the neck (LR = 0.11, 95% CI, 0.06-0.23, P < 0.05) rules against AS of at least moderate severity.
Low-quality evidence from observational studies supports a diminished second heart sound and a delayed carotid upstroke as having moderate accuracy in diagnosing the presence of AS of at least moderate severity, whereas the absence of a murmur radiating to the neck is equally accurate in excluding this diagnosis.
Les patients présentant une obstruction de la voie d’éjection ventriculaire gauche consécutive à une sténose aortique (SA) dégénérative ne montrent habituellement pas de symptômes avant que la maladie ne soit de grade sévère. Nous cherchions donc à évaluer la fiabilité des examens physiques dans le diagnostic de SA modérée ou plus grave.
Une revue systématique et une métanalyse de séries de cas et de cohortes de patients qui ont subi un examen cardiovasculaire avant de recevoir un cathétérisme du côté gauche du cœur ou un échocardiogramme ont été effectuées. Les bases de données PubMed, Ovid MEDLINE, Cochrane, ClinicalTrials.gov et Embase ont été interrogées pour trouver les études publiées entre la date de début de l’indexation des bases jusqu’au 10 décembre 2021, sans restriction quant à la langue de publication.
Notre revue systématique a permis de relever sept études observationnelles contenant des données permettant de réaliser une métanalyse sur trois examens physiques. La présence d’un deuxième bruit diminué à l’auscultation (quotient de vraisemblance [QV] : 10,87; intervalle de confiance [IC] à 95 % : 3,94 à 30,12; p < 0,05) et d'un flux carotidien démodulé à la palpation (QV : 9,04; IC à 95 % : 3,12 à 25,44; p < 0,05) permet de détecter une SA modérée ou plus grave. L’absence d’un souffle systolique irradiant jusqu’au cou (QV : 0,11; IC à 95 % : 0,06 à 0,23; p < 0,05) permet d’éliminer la possibilité de SA modérée ou plus grave.
Les données de faible qualité provenant d’études observationnelles témoignent d’une fiabilité modérée d’un deuxième bruit diminué et d’un flux carotidien démodulé dans le diagnostic de SA modérée ou plus grave, alors que l’absence d’un souffle irradiant jusqu’au cou présente la même fiabilité dans l’exclusion de ce diagnostic.
Impact of Moderate Aortic Stenosis on Long-Term Clinical Outcomes: A Systematic Review and Meta-Analysis
2022, JACC: Cardiovascular Interventions
Citation Excerpt :
Almost all studies (23 of 25) calculated the AVA using the continuity equation alone or combined with other Doppler criteria (maximum velocity, mean gradient, and dimensionless index). Except for the 4 oldest studies,18-21 all used an AVA between 1 and 1.5 cm2 to define moderate AS, which probably reduced the heterogeneity in patient selection of the studies included in this meta-analysis. Besides, the distinction between moderate AS and low-flow, low-gradient severe AS is challenging and often requires further testing such as dobutamine stress echocardiography or calcium scoring by computed tomography scan.
The clinical course of patients with moderate aortic stenosis (AS) remains incompletely defined.
This study sought to analyze the clinical course of moderate AS and compare it with other stages of the disease.
Multiple electronic databases were searched to identify studies on adult moderate AS. Random-effects models were used to derive pooled estimates. The primary endpoint was all-cause death. The secondary endpoints were cardiac death, heart failure, sudden death, and aortic valve replacement.
Among a total of 25 studies (12,143 moderate AS patients, 3.7 years of follow-up), pooled rates per 100 person-years were 9.0 (95% CI: 6.9 to 11.7) for all-cause death, 4.9 (95% CI: 3.1 to 7.5) for cardiac death, 3.9 (95% CI: 1.9 to 8.2) for heart failure, 1.1 (95% CI: 0.8 to 1.5) for sudden death, and 7.2 (95% CI: 4.3 to 12.2) for aortic valve replacement. Meta-regression analyses detected that diabetes (P = 0.019), coronary artery disease (P = 0.017), presence of symptoms (P < 0.001), and left ventricle (LV) dysfunction (P = 0.009) were associated with a significant impact on the overall estimate of all-cause death. All-cause mortality was higher in patients with reduced LV ejection fraction (<50%) than with normal LV ejection fraction: 16.5 (95% CI: 5.2 to 52.3) and 4.2 (95% CI: 1.4 to 12.8) per 100 person-years, respectively. Compared with moderate AS, the incidence rate difference of all-cause mortality was -3.9 (95% CI: -6.7 to -1.1) for no or mild AS and +2.2 (95% CI: +0.8 to +3.5) for severe AS patients.
Moderate AS appears to be associated with a mortality risk higher than no or mild AS but lower than severe AS, which increases in specific population subsets. The impact of early intervention in moderate AS patients having high-risk features deserves further investigation.
Blowing it up: A Review of Balloon-Expandable Transcatheter Aortic Valve Replacement
2021, Interventional Cardiology Clinics
Impact of annular and supra-annular CoreValve deployment locations on aortic and coronary artery hemodynamics
2018, Journal of the Mechanical Behavior of Biomedical Materials
CoreValve is widely used in transcatheter aortic valve replacement, but the impact of its deployment location on hemodynamics is unexplored despite a potential role in subsequent aortic and coronary artery pathologies. The objectives of this investigation were to perform fluid-structure interaction (FSI) simulations for a 29 mm CoreValve deployed in annular vs supra-annular locations, and characterize resulting hemodynamics including velocity and wall shear stress (WSS). Patient-specific geometry was reconstructed from computed tomography scans and CoreValve was deployed using a finite element approach. FSI simulations were then performed using a boundary conforming method and realistic boundary conditions. Results showed that CoreValve deployment location impacts hemodynamics in the ascending aorta and flow patterns in the coronary arteries. During peak-systole, annularly deployed CoreValve produced a jet-like flow structure impinging on the outer-curvature of the ascending aorta. Supra-annularly deployed CoreValve having a lateral tilt of 10° led to a more centered jet impinging further downstream. At mid-systole, valve leaflets of the annularly deployed CoreValve closed asymmetrically leading to disorganized flow patterns in the ascending aorta vs those from the supra-annular position. Supra-annularly deployed CoreValve also led to high-velocity para-valvular flow supplying the coronary arteries. CoreValve in the supra-annular position significantly (P < 0.05) elevated WSS within the first few diameters of both coronary arteries as compared to the annular position for many time points quantified. These results afforded by the advanced simulation methods may have important clinical implications given the role of aortic hemodynamics in dilation and the pro-atherogenic nature of WSS alterations in the coronary arteries.
Evaluation and Management of Aortic Stenosis for the Emergency Clinician: An Evidence-Based Review of the Literature
2018, Journal of Emergency Medicine
Aortic stenosis is a common condition among older adults that can be associated with dangerous outcomes, due to both the disease itself and its influence on other conditions.
This review provides an evidence-based summary of the current emergency department (ED) evaluation and management of aortic stenosis.
Aortic stenosis refers to significant narrowing of the aortic valve and can be caused by calcific disease, congenital causes, or rheumatic valvular disease. Symptoms of advanced disease include angina, dyspnea, and syncope. Patients with these symptoms have a much higher mortality rate than asymptomatic patients. Initial evaluation should include an electrocardiogram, complete blood count, basic metabolic profile, coagulation studies, troponin, brain natriuretic peptide, type and screen, and a chest radiograph. Transthoracic echocardiogram is the test of choice, but point-of-care ultrasound has been found to have good accuracy when a formal echocardiogram is not feasible. Initial management should begin with restoring preload and ensuring a normal heart rate, as both bradycardia and tachycardia can lead to clinical decompensation. For patients with high blood pressure and heart failure symptoms, nitrate agents may be reasonable, but hypotension should be avoided. Dobutamine can increase inotropy. For hypotensive patients, vasopressors should be used at the lowest effective dose. The treatment of choice is valve replacement, but extracorporeal membrane oxygenation and percutaneous balloon dilatation of the aortic valve have been described as temporizing measures.
Aortic stenosis is an important condition that can lead to dangerous outcomes and requires prompt recognition and disease-specific management in the ED.
Prognostic Implications of Moderate Aortic Stenosis in Patients With Left Ventricular Systolic Dysfunction
2017, Journal of the American College of Cardiology
Left ventricular (LV) systolic dysfunction and moderate aortic stenosis (AS) are more frequent with advancing age and often coexist. Afterload reduction is the mainstay of pharmacological treatment of heart failure (HF). Aortic valve replacement (AVR) is only formally indicated for symptomatic severe AS.
This study sought to determine the clinical outcome of patients with concomitant moderate AS and LV systolic dysfunction.
Echocardiographic and clinical data of patients with moderate AS and LV systolic dysfunction between 2010 and 2015 from 4 large academic institutions were retrospectively analyzed. Moderate AS was defined as aortic valve area between 1.0 and 1.5 cm² and LV systolic dysfunction defined as LV ejection fraction <50%. The primary endpoint was a composite of all-cause death, AVR, and HF hospitalization.
A total of 305 patients (mean age 73 ± 11 years; 75% male) were included. The majority were symptomatic at the time of index echocardiogram (New York Heart Association [NYHA] functional class II: 42%; NYHA functional class III: 28%; and NYHA functional class IV: 4%). Ischemic heart disease was present in 72% of patients. At 4-year follow-up, the primary composite endpoint occurred in 61%. The main predictors for the primary endpoint were male sex (p = 0.022), NYHA functional class III or IV (p < 0.001), and peak aortic jet velocity (p < 0.001). The rate of the composite of all-cause death or HF hospitalization was 48%, rate of all-cause death was 36%, and rate of HF hospitalization was 27%. AVR occurred in 24% of patients.
Patients with concomitant moderate AS and LV systolic dysfunction are at high risk for clinical events. Further studies are needed to determine if earlier AVR in these patients might improve clinical outcome.

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^☆: This study was supported by a grant from Heart Research Foundation (Sydäntutkimussäätiö), Helsinki, Finland.

¹: Dr. Kupari's address is: Division of Cardiology, Helsinki University Central Hospital, FIN-00290 Helsinki, Finland.

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Brief reportNatural history of aortic valve stenosis of varying severity in the elderly☆

Abstract

Am Heart J

Am Heart J

Am J Cardiol

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

Am J Cardiol

Aortic stenosis

Circulation

Brief report
Natural history of aortic valve stenosis of varying severity in the elderly☆