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Predictors of Progression in Stage B Aortic Regurgitation
Study Questions:
What are the determinants, rate, and consequences of progression of aortic regurgitation (AR)?
Methods:
Consecutive patients at a single institution with ≤ moderate chronic AR quantified by effective regurgitant orifice area (EROA) and regurgitant volume (RV) from 2004 to 2017 and who had ≥1 subsequent echocardiogram with quantitation were retrospectively studied. AR that was ≥ moderate-to-severe on a subsequent echocardiogram was taken as evidence of progression.
Results:
Of 1,077 patients (66 ± 15 years of age), baseline trivial/mild AR was present in 196 (18%), mild-to-moderate AR in 465 (43%), and moderate AR in 416 (39%). For those degrees of baseline AR, the 10-year incidence of progression to ≥ moderate-severe AR (stage C/D; progressors) was 12%, 30%, and 53%, respectively. At 4.1-year follow-up (interquartile range [IQR], 2.1-7.2 years), there were 228 progressors (21%), whose annualized progression rates within 3 years before diagnosis of ≥ moderate-severe AR were 4.2 mm2/year for EROA and 9.9 ml/year for RV. Baseline AR severity and dimensions of the sinotubular junction and annulus were associated with progression (all p ≤ 0.007); hypertension and systolic blood pressure were not. Progressors had faster chamber remodeling, functional class decline, and more aortic valve/aortic surgery. At a median follow-up of 5.0 (IQR, 2.7-7.8) years, 242 patients (22%) died; poor survival was linked to age, comorbidities, functional class, resting heart rate, and left ventricular (LV) ejection fraction (p ≤ 0.003), but not LV end-systolic dimension index. Survival after progression to stage C/D AR was associated with LV end-systolic dimension index (adjusted p = 0.02).
Conclusions:
Progression from stage B to stage C/D AR was observed in 21% of patients at a median follow-up of 4.1 years. Repeat echocardiography for trivial/mild, mild-to-moderate, and moderate AR at every 5, 3, and 1 year, respectively, was reasonable. The authors recommend that EROA, RV, annulus, and sinotubular junction should be routinely measured to estimate progression rates and identify patients at high risk of progression, which was associated with adverse consequences.
Perspective:
This large, single-center, retrospective study used quantitative echo/Doppler data (EROA, RV) to look for predictors and the rate of AR progression from stage B (≤ moderate) to stage C/D (in this study, moderate-to-severe as well as severe). Based on the rate of progression, routine repeat echocardiography at intervals provided in the current American Heart Association/American College of Cardiology valvular heart disease guideline (every 3-5 years for stage B mild AR, every 1-2 years for stage B moderate AR) appear reasonable. However, larger aortic annular and sinotubular junction diameters, and greater AR severity were found to correlate with greater AR progression, suggesting that closer follow-up may be appropriate among some patients.
Keywords: Aortic Valve Insufficiency, Blood Pressure, Comorbidity, Diagnostic Imaging, Echocardiography, Echocardiography, Doppler, Heart Failure, Heart Rate, Heart Valve Diseases, Hypertension, Stroke Volume
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