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Mild Valvular Lesions and Long-Term CV Outcomes in Black Adults
Quick Takes
- In this observational study of 2,106 middle-aged Black adults, aortic sclerosis and trace/mild aortic regurgitation both demonstrated independent associations with cardiovascular (CV) mortality (adjusted hazard ratios, 1.54 and 1.75, respectively).
- The presence of multiple mild valve lesions was associated with CV outcomes in a dose-dependent fashion. Survival free of CV mortality at 20 years was 74.9% in participants with 2-3 lesions, 85.7% in those with one lesion, and 92.6% in those with no lesions.
Study Questions:
What are the associations of three mild valvular lesions (aortic sclerosis, trace or mild aortic regurgitation [AR], and trace or mild mitral regurgitation [MR]) with adverse cardiovascular (CV) events in Black adults?
Methods:
This was a substudy of ARIC (Atherosclerosis Risk in Communities), an ongoing, prospective, community-based cohort study that began at four US sites in 1987 and enrolled participants aged 45-64 years. Echocardiograms were performed only at the Jackson, Mississippi site, where only Black participants were enrolled. From the group of patients with echocardiograms, those with more advanced valve lesions (aortic stenosis, moderate or greater AR, and moderate or greater MR) were excluded for the purposes of the substudy. Mild valve lesions of interest were aortic sclerosis, trace or mild AR, and trace or mild MR. Study outcomes were CV mortality and incident diagnoses of coronary artery disease (CAD), stroke, heart failure (HF), and atrial fibrillation (AF).
Results:
A total of 2,106 Black participants (mean age 59.1 years, 64.3% women) were included. Aortic sclerosis was present in 7.7%, trace or mild AR in 15.1%, and trace or mild MR in 43.0%. Aortic sclerosis was more common among individuals with diabetes and those with a history of smoking. During a median follow-up period of 22.5 years, 890 of 2,106 participants (42.3%) developed ≥1 CV outcome. The most frequent outcome was HF (27.3%), followed by AF (14.5%), stroke (13.1%), CAD (11.3%), and CV mortality (10.5%).
Based on Kaplan-Meier analyses, participants with aortic sclerosis, trace or mild AR, and mild MR (but not trace MR) had decreased survival free of CV death compared with their counterparts. After adjustment for potential confounders (age, sex, diabetes, and others), aortic sclerosis demonstrated independent association with CV mortality (adjusted hazard ratio [aHR], 1.54; 95% confidence interval [CI], 1.06-2.22, p < 0.05). Trace or mild AR was independently associated with all outcomes except stroke (for instance, aHR for CV mortality, 1.75; 95% CI, 1.29-2.37, p < 0.001). Mild MR was independently associated with AF (aHR, 1.47; 95% CI, 1.09-1.99, p < 0.05).
The presence of multiple valve lesions was associated with each CV outcome in a dose-dependent fashion, although the association for stroke did not reach statistical significance. Survival free of CV mortality at 20 years was 74.9% in participants with 2-3 lesions, 85.7% in those with one lesion, and 92.6% in those with no lesions.
Conclusions:
In middle-aged Black individuals, mild valve lesions including aortic sclerosis, trace to mild AR, and mild MR are associated with adverse CV outcomes and CV mortality.
Perspective:
The results of this study suggest that seemingly mild aortic and mitral valve changes have prognostic significance even in the absence of hemodynamically significant valve dysfunction. The findings are not surprising, in light of the following associations: 1) aortic sclerosis is often a consequence of comorbidities such as chronic kidney disease and can be a harbinger of aortic stenosis, 2) AR may result from aortic sclerosis and/or aortic root dilation, and 3) MR is often related to mitral annular dilation in the setting of left atrial and/or left ventricular dilation and AF.
In clinical practice, follow-up plans and management often differ based on valve anatomy, regurgitation mechanism, and accompanying ventricular pathology, and such data were not included in the study. Mitral annular calcification, in particular, has clear associations with adverse CV outcomes. As with all observational studies, residual confounding may have impacted the results. Black individuals are generally at higher risk of the CV outcomes studied, and it is possible that the relationships between mild valve lesions and outcomes would differ in other populations.
Clinical Topics: Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Prevention, Valvular Heart Disease, Atherosclerotic Disease (CAD/PAD), Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure, Echocardiography/Ultrasound, Smoking, Mitral Regurgitation
Keywords: African Americans, Aortic Valve Insufficiency, Aortic Valve Stenosis, Atherosclerosis, Atrial Fibrillation, Coronary Artery Disease, Diabetes Mellitus, Diagnostic Imaging, Dilatation, Echocardiography, Heart Failure, Heart Valve Diseases, Mitral Valve Insufficiency, Renal Insufficiency, Chronic, Sclerosis, Smoking, Stroke
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