Cardiac Damage in Patients With Asymptomatic Aortic Stenosis

Jul 23, 2019
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Authors:
Tastet L, Tribouilloy C, Maréchaux S, et al.
Citation:
Staging Cardiac Damage in Patients With Asymptomatic Aortic Valve Stenosis. J Am Coll Cardiol 2019;74:550-563.
Summary By:
David S. Bach, MD, FACC

Study Questions:

Does an echo/Doppler staging system assessing cardiac abnormalities distinct from the aortic valve help predict all-cause mortality among asymptomatic patients with moderate or severe aortic stenosis (AS)?

Methods:

Prospectively collected clinical, Doppler echocardiographic, and outcome data were retrospectively analyzed for 735 asymptomatic patients (71 ± 14 years of age; 60% men) with at least moderate AS (aortic valve area <1.5 cm2) and preserved left ventricular ejection fraction (LVEF ≥50%) followed in the heart valve clinic at one of four high-volume centers. Patients were classified according to a recently defined staging classification that addresses cardiac abnormalities distinct from the aortic valve among patients with AS:

  • Stage 0: No cardiac damage associated with AS
  • Stage 1: LV damage defined by LV hypertrophy (LV mass index >115 g/m2 in men or >95 g/m2 in women) and/or mitral E/e’ >14 and/or LVEF <60%
  • Stage 2: Left atrial (LA) or mitral valve damage defined by LA volume index >34 ml/m2 and/or atrial fibrillation and/or ≥ moderate mitral regurgitation
  • Stage 3: Pulmonary vasculature or tricuspid valve damage defined by pulmonary artery systolic pressure >60 mm Hg and/or ≥ moderate tricuspid regurgitation
  • Stage 4: Right ventricular (RV) damage or subclinical heart failure defined by a multiparameter approach including semiquantitative assessment by visual examination and quantitative assessment using tricuspid annulus systolic velocity S’ <9.5 cm/s and/or tricuspid annular plane systolic excursion <17 mm

The primary study endpoint was all-cause mortality.

Results:

At baseline, 89 (12%) patients were classified in Stage 0, 200 (27%) in Stage 1, 341 (46%) in Stage 2, and 105 (14%) in Stage 3 or 4. Median follow-up was 2.6 years (interquartile range, 1.1-5.2 years). There was a stepwise increase in mortality rates according to staging: 13% in Stage 0, 25% in Stage 1, 44% in Stage 2, and 58% in Stages 3-4 (p < 0.0001). The staging was significantly associated with excess mortality in multivariable analysis adjusted for aortic valve replacement as a time-dependent variable (hazard ratio, 1.31 per each increase in stage, 95% confidence interval, 1.06-1.61; p = 0.01), and showed incremental value to several clinical variables (net reclassification index = 0.34, p = 0.003).

Conclusions:

The new staging system characterizing extra-aortic valve cardiac damage provided incremental prognostic value in patients with asymptomatic moderate or severe AS. The authors propose that this staging classification may be helpful to identify asymptomatic patients with AS who might benefit from elective aortic valve replacement.

Perspective:

The proposed staging system is intriguing, and suggests that patients with moderate or severe AS and evidence of LV hypertrophy or LVEF 50-60%; LA enlargement, elevated LV filling pressures, atrial fibrillation, or mitral regurgitation; pulmonary hypertension or significant tricuspid regurgitation; or abnormal RV function are at progressively higher risk of all-cause death. However, the same or similar factors are known to define risk among patients without AS. Although an association was demonstrated between risk factors (stages) and mortality, whether timing aortic valve intervention based on this staging system affects clinical outcomes remains conjectural. (See the related article: Vollema EM, et al., J Am Coll Cardiol 2019;74:538-49).

Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Cardiovascular Care Team, Diabetes and Cardiometabolic Disease, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Pulmonary Hypertension and Venous Thromboembolism, Valvular Heart Disease, Atrial Fibrillation/Supraventricular Arrhythmias, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Acute Heart Failure, Pulmonary Hypertension, Interventions and Imaging, Interventions and Structural Heart Disease, Interventions and Vascular Medicine, Echocardiography/Ultrasound, Hypertension, Mitral Regurgitation

Keywords: Aortic Valve Stenosis, Atrial Fibrillation, Blood Pressure, Cardiac Surgical Procedures, Echocardiography, Doppler, Geriatrics, Heart Failure, Heart Valve Diseases, Heart Valve Prosthesis, Hypertension, Pulmonary, Hypertrophy, Mitral Valve Insufficiency, Risk Factors, Stroke Volume, Systole, Transcatheter Aortic Valve Replacement, Tricuspid Valve Insufficiency


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