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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Article info
Publication history
Published online: November 20, 2019
Accepted:
November 15,
2019
Received:
September 11,
2019
Footnotes
See editorial by Fountotos and Afilalo, pages 1000–1002 of this issue.
See page 1111 for disclosure information.
Identification
Copyright
© 2019 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
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