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Canadian Journal of Cardiology

Clinical Impact of Valvular Heart Disease in Elderly Patients Admitted for Acute Coronary Syndrome: Insights From the Elderly-ACS 2 Study

Published:November 20, 2019DOI:https://doi.org/10.1016/j.cjca.2019.11.014

      Abstract

      Background

      Elderly patients are under-represented in clinical trials and registries, and a gap of evidence exists for clinical decision making in the setting of acute coronary syndromes (ACS). We aimed to assess the prevalence and independent prognostic impact of valvular heart disease (VHD) diagnosed during the index hospitalization on clinical outcomes among elderly patients with ACS. Included VHDs were moderate-to-severe mitral regurgitation (MR), moderate-to-severe aortic stenosis (AS), or both combined.

      Methods

      We explored the Elderly-ACS 2 dataset, which includes patients older than 74 years of age diagnosed with ACS and managed invasively. The primary endpoint was a composite of all-cause death, myocardial infarction, disabling stroke, and rehospitalization for heart failure at 1 year; the secondary endpoint was death for cardiovascular causes. Patients were stratified into 4 groups: no VHD, moderate-to-severe MR, moderate-to-severe AS, and both moderate-to-severe MR and AS.

      Results

      Of the 1443 subjects enrolled, 190 (13.2%) had moderate-to-severe MR, 26 (1.8%) had moderate-to-severe AS, and 13 (0.9%) had both moderate-to-severe MR and AS. When compared with those with no VHD, patients with moderate-to-severe MR had hazard ratios (HRs) for the primary endpoint of 2.04 (95% confidence interval [CI], 1.36-3.07], those with moderate-to-severe AS had HRs of 3.10 (95% CI, 1.39-6.93), and those with both moderate-to-severe MR and AS had HRs of 4.00 (95% CI, 1.65-9.73] (all P < 0.01). Patients with moderate-to-severe MR also had increased risks of cardiovascular death (HR 3.17; 95% CI, 1.57-6.42; P < 0.01), whereas in those with moderate-to-severe AS or both moderate-to-severe MR and AS, a nonsignificant increased risk was observed.

      Conclusions

      In a contemporary cohort of elderly patients admitted for ACS, VHD was found in 1 of 5 subjects and had an independent, consistent impact on prognosis.

      Résumé

      Contexte

      Une sous-représentation des patients âgés existe dans les essais cliniques et les registres, et il s’ensuit un manque de données probantes pour la prise de décisions cliniques dans le contexte des syndromes coronariens aigus (SCA). Nous avons entrepris d’évaluer la prévalence de valvulopathies diagnostiquées lors de l’hospitalisation de référence et leur incidence pronostique indépendante d’après les résultats cliniques chez des patients âgés souffrant de SCA. Les valvulopathies comprenaient la régurgitation mitrale (RM) et la sténose aortique (SA), modérées ou sévères, concomitantes ou non.

      Méthodologie

      Nous avons examiné les données de l’étude Elderly ACS 2, portant notamment sur des patients de plus de 74 ans ayant reçu un diagnostic de SCA et subi une intervention invasive. Le paramètre d’évaluation principal regroupait les décès toutes causes confondues, l’infarctus du myocarde, l’AVC invalidant et la réhospitalisation pour cause d’insuffisance cardiaque après un an; les décès d’origine cardiovasculaire constituaient le paramètre d’évaluation secondaire. Les patients ont été stratifiés en quatre groupes correspondant à leur état : sans valvulopathie; RM modérée ou sévère; SA modérée ou sévère; RM et SA modérées ou sévères concomitantes.

      Résultats

      Parmi les 1 443 sujets inscrits, 190 (13,2 %) présentaient une RM modérée ou sévère; 26 (1,8 %), une SA modérée ou sévère; 13 (0,9 %), une RM et une SA modérées ou sévères concomitantes. Le rapport des risques instantanés (RRI) au regard du paramètre d'évaluation principal était de 2,04 (intervalle de confiance [IC] à 95 %, 1,36-3,07] chez les patients présentant une RM modérée ou sévère, de 3,10 (IC à 95 %, 1,39-6,93) chez les patients présentant une SA modérée ou sévère et de 4,00 (IC à 95 %, 1.65-9,73] chez les patients présentant une RM et une SA modérées ou sévères concomitantes, comparativement aux patients sans valvulopathie (p < 0,01 dans tous les cas). En outre, les patients présentant une RM modérée ou sévère étaient exposés à un risque accru de décès d’origine cardiovasculaire (RRI de 3,17; IC à 95 %, 1,57-6,42; p < 0,01), tandis qu’une augmentation non significative du risque a été observée chez les patients présentant une SA modérée ou sévère et chez les patients présentant une RM et une SA modérées ou sévères concomitantes.

      Conclusions

      Au sein d’une cohorte contemporaine de patients âgés hospitalisés dans un contexte de SCA, un sujet sur cinq présentait une valvulopathie ayant eu une incidence indépendante et constante sur le pronostic.
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      Linked Article

      • Heart Valve Dysfunction in Ischemic Heart Disease: Epiphenomenon of Cardiac Aging and Damage?
        Canadian Journal of CardiologyVol. 36Issue 7
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          In medicine, an epiphenomenon is a secondary clinical finding that manifests alongside a primary phenomenon but has little to no causal influence itself. The epiphenomenon may be a useful indicator to establish the diagnosis or prognosis of a related condition; yet, paradoxically, it may not be a worthwhile target to treat the condition or prevent its undesirable outcomes. Therefore, ascertaining causal influence is critical to foreshadow whether an association suggested by observational research will likely translate into positive clinical trials and new treatment paradigms.
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