evaluation and management of asymptomatic aortic stenosis.€¦ · evaluation and management of...
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Evaluation and Management of
Asymptomatic Aortic Stenosis.
Augusto Pichard, M.D.
Director Innovation and Structural Heart Disease,
Vice Chair, Medstar Heart Institute,
Medstar Washington Hospital Center.
Professor of Medicine (Cardiology),
Georgetown University Medical School.
Washington, DC
Symptoms of Aortic Stenosis
• Main symptoms: – dyspnea,
– angina,
– syncope,
• Other important symptoms: – dizziness,
– weakness,
– fatigue,
– exercise intolerance.
• Patients may not be aware of symptoms.
Case Presentation
History: 87 female, very active until recently. Now uses wheel chair for mobilization, pushed by
someone else. Sleeps on recliner. Obese 220 lbs.
Anamnesis: do you have • SOB? NO • Orthopnea or PND? NO • Leg swelling? Mild in both legs, present for
years. • Chest pain? NO • Dizziness or passing out? NO
AVA: 0.6 cm2 (Index 0.3).
Mean Gradient: 48 mm Hg.
Average Max V2: 4.4 m/s. EF 35%.
Mild MR, Trace AI.
LVOT 1.9cm, Annulus 23cm.
PA systolic pressure 55 mm Hg.
Echocardiogram
Mild Coronary Disease
Case Summary
1. She “thinks” she is asymptomatic, but she
is not: cannot lye flat, barely moves,
always fatigued (FC III?).
2. No need for exercise test or Dobutamine
Echo: she has critical AS.
3. Depending on family support and
personal drive, could be good candidate
for TAVI or high risk AVR.
Second Case Presentation
64 year old male
• 180 lbs.
• Exercises on treadmill 30 min daily,
without symptoms.
• Plays golf weekly.
• Works full time as University Professor.
Cinical Data
Past history:
• Pancreatitis 2002 followed by:
- major weight loss (from 300 to 200 lbs).
- cessation of alcohol intake.
• Prior smoker
• Normal coronaries by cath in 2000
Echo:
• AVA 0.9 cm2 (index 0.55)
• Mean gradient 30 mm Hg
• V max 3 m/sec
Rest Exercise
• BP 120/76 • HR 96, AF • EF 50%. • Mean Ao gradient 30 mm Hg.
• Stage 3 Bruce • BP 190/84 • No symptoms. • HR 203, AF • EF 75% (Excellent reserve). • Exercise gradient: 32 mm Hg
(residual valve compliance).
Mortality of Asymptomatic
Severe Aortic Stenosis
1993-2003 Loma Linda Echo Lab Database.
747 Patients with AVA <0.8 cm2: 338 asymptomatic.
Pai et al. Ann Thor Surg 2006;82:2116-22
Asymptomatic Patients
Valve Replacement
No surgery
Incidence of Sudden Death in
Asymptomatic Aortic Stenosis
Rahimtoola EHJ 2008; 29:1783-91.
Lancelotti AJC 2010 126 4.8
Patients
n=
26
128
66
69
125
622
Rahimtoola, EHJ 08
Outcome of Asymptomatic Aortic Stenosis Pellikka et al. Circulation 2005;111:3290-5
During 5 year follow up:
• 57% had AVR
• 43% died (19% cardiac
death).
• Sudden death without preceding
symptoms occurred in 4.1% of 270
unoperated patients
622 patients with peak veloc >4m/sec, AVA 0.9±0.2cm2
2 y
5 y
First Concept
Patients with severe Aortic Stenosis
and no symptoms
can have
significant morbidity/mortality.
Echo Predictors of events
Predictors of Events in Asymptomatic Aortic Stenosis
Otto et al. Circulation 1997, 95:2262
Echo Predictors (all p<.001) :
• jet velocity,
• mean gradient,
• valve area,
• rate of increase in jet velocity.
• LA size and LV mass.
Aortic Jet Velocity and EFS
Otto et al. Circulation 1997, 95:2262
20% events at 5 years
40% events at 4 years
80% events at 3 years
100% events at 5 years
123 AS patients without symptoms
Jet Velocity, AVA and Outcome Otto et al. Circulation 1997, 95:2262
AVA
cm2
Ao Jet
Veloc.
m/sec
Jet Velocity Progression and Outcome
in Severe Asymptomatic Aortic Stenosis Rosenhek et al. NEJM 2000; 343:611-7
Mean Rate of Progression of Aortic-Jet
Velocity among 41 Patients with and 29
patients without Cardiac Events
34 Patients with Moderate or Severe
Calcification of the Aortic Valve and a Rapid
Increase in Aortic-Jet Velocity (at Least 0.3
m/sec within 1 Year).
>0.3 m/sec/year
Valve Calcification is a Predictor of Outcome in Severe Asymptomatic AS
Rosenhek et al. NEJM 2000; 343:611-7
Calcification by CT predicts outcome in asymptomatic AS. J Heart Valve Dis 2007;15:494
Exercise Test
in Asymptomatic Aortic Stenosis
Exercise testing in Asymptomatic AS Amato et al. Heart 2001; 86:381-6
Although asymptomatic in daily life, 6% of the patients (4/66)
experienced sudden death: all with positive exercise test and aortic
valve area 0.6 cm2.
Incremental Prognostic Value of Exercise Test Lancelotti et al. Circul 2005;112:I 377-82
Predictive
value
Why Operate Early ?
Severe AS, even asymptomatic, has
• Up to 6% incidence of SD.
• Very low surgical mortality/morbidity.
• Higher surgical mortality when more
symptomatic.
Mortality for AVR. STS Executive Summary 2008
www.sts.org
<10% of patients had STS >10
AVR in the Elderly.
Cerillo et al. Interact CardioVasc Thorac Surg 2007;6:308-13
Surgery for Asymptomatic Severe AS. Kand, Park et al. Circulation 2010;121:1502-9
197 asymptomatic patients with severe AS:
AVA <.75cm2, Mean grad >50 mm Hg, Jet velocity > 4.5m/sec,.
During a median follow-up of 1501 days, the operated group had no operative
mortalities, no cardiac deaths, and 3 noncardiac deaths; the conventional
treatment group had 18 cardiac and 10 noncardiac deaths.
If no Operation Indicated, What is
the Rate of Progression of AS ?
Progression of Aortic Stenosis Palta et al. Circ 2000, 101:2497-2502
174 patients with 2 TTE 23±11 months
apart.
Rate of progression:
- 0.1±0.27 cm2 per year
- Double if cholesterol > 200 mg
- Increased with high creatinine,
high serum calcium, smoking
and severe initial AVA.
Statins and Progression of AS
Am J Cardiol 2008;102:738 –742
1046 patients, 309 with Statins
At 5 years, Statin slowed progression in those with mild or moderate AS.
N Engl J Med 2008;359:1343-56, JACC 2009;53:A415.
1873 pts randomized. Statins did not decrease MACE at 52 months, but decreased CVA’s, and ischemic events.
Circulation. 2004;110:1291-1295.
206 patients. Statins, but not ACE inhibitors slowed progression of AS
J Am Coll Cardiol 2007;49:554–61
120 pts randomized. Rosuvastatin slowed progression of AS.
Briand. JACC 2006;47:2229-36
Metabolic syndrome doubles the rate of progression of AS.
Chan. Circulation 2010 121:306-14 Astronomer Trial.
269 pts randomized. Rosuvastatin 40 mg in mild to moder AS did not reduce progression.
Metabolic Syndrome and Progression of AS. Copoulade, Pibarot et al. JACC 2012;60:169-180
CAD in Patients with Severe AS. WHC: Ben-Dor et al. Circulation 2010;122:S37-42
Patients with CAD had higher risk scores, more females,
more PVD and lower EF.
Conclusions
• Asymptomatic Severe AS is a serious condition associated with mortality.
• Some patients “report” no symptoms in spite of significant limitations.
• Stress test indicated in truly asymptomatic AS.
• AVR improves prognosis in asymptomatic AS if the patient has high risk echo features or abnormal Exercise Test.
The end