Advertisement
Canadian Journal of Cardiology

Long-term Prognosis in Patients With Concomitant Acute Coronary Syndrome and Aortic Stenosis

Published:March 18, 2022DOI:https://doi.org/10.1016/j.cjca.2022.03.010

      Abstract

      Background

      Aortic stenosis (AS) and acute coronary syndrome (ACS) share similar cardiovascular risk factors. The incidence of concomitant AS and ACS is increasing with aging population, yet studies investigating the prognosis of these patients remain scarce.

      Methods

      This retrospective single-centre cohort study examined consecutive patients who presented with ACS and AS from January 1, 2011, to March 31, 2021. The cohort was divided into mild, moderate, and severe AS based on the index echocardiogram. The primary outcome was all-cause mortality.

      Results

      Of 563 patients, 264 (46.9%) had mild, 193 (34.3%) moderate, and 106 (18.8%) severe AS. The mean follow-up duration was 2.5 years. All-cause mortality was higher among patients with moderate and severe AS compared with mild AS within 30 days (17.0% vs 13.0% vs 6.4%, respectively; P = 0.005) and in the long term (49.7% vs 51.4% vs 35.6%; P = 0.002). Concomitant moderate (hazard ratio [HR] 1.453, 95% confidence interval [CI] 1.020-2.068; P = 0.038) or severe AS (HR 1.873, 95% CI 1.176-2.982; P = 0.008) was an independent predictor of all-cause mortality. Kaplan-Meier curves demonstrated higher mortality in patients with moderate and severe AS compared with mild AS (P < 0.001). Similar survival trends were observed regardless of ACS type and in those with preserved left ventricular ejection fraction. Patients with reduced left ventricular ejection fraction had poor prognosis regardless of AS severity.

      Conclusions

      ACS patients with concomitant moderate or severe AS have similar high long-term mortality, regardless of ACS type. The high early mortality in moderate and severe AS emphasises the imperative to attempt to mitigate this risk urgently.

      Résumé

      Contexte

      La sténose aortique (SA) et le syndrome coronarien aigu (SCA) ont des facteurs de risque cardiovasculaire similaires. L’incidence de SA et de SCA concomitants augmente parallèlement au vieillissement de la population, mais on trouve peu d’études sur le pronostic des patients atteints de ces cardiopathies.

      Méthodologie

      Cette étude de cohorte monocentrique rétrospective porte sur des patients consécutifs ayant présenté un SCA et une SA entre le 1er janvier 2011 et le 31 mars 2021. La cohorte a été divisée en trois groupes de cas correspondant à la gravité de la SA, soit légère, modérée ou sévère, en fonction de l’échocardiogramme initial. Le paramètre d’évaluation principal était la mortalité toutes causes confondues.

      Résultats

      Parmi les 563 patients recensés, 264 (46,9 %) présentaient une SA légère, 193 (34,3 %), une SA modérée et 106 (18,8 %), une SA sévère. La durée moyenne du suivi était de 2,5 ans. La mortalité toutes causes confondues était plus élevée chez les patients présentant une SA modérée ou sévère que chez les patients présentant une SA légère, sur 30 jours (17,0 % vs 13,0 % vs 6,4 %, respectivement; P = 0,005) et à long terme (49,7 % vs 51,4 % vs 35,6 %; P = 0,002). La SA concomitante modérée (rapport des risques instantanés [RRI] : 1,453; intervalle de confiance [IC] à 95 % : 1,020-2,068; P = 0,038) ou sévère (RRI : 1,873, IC à 95 % : 1,176-2,982; P = 0,008) constituait un facteur prédictif indépendant de mortalité toutes causes confondues. Les courbes de Kaplan-Meier ont révélé que la mortalité était plus élevée chez les patients présentant une SA modérée ou sévère que chez les patients présentant une SA légère (P < 0,001). Des tendances de survie similaires ont été observées indépendamment du type de SCA et chez les patients présentant une fraction d’éjection ventriculaire gauche préservée. Le pronostic était sombre chez les patients présentant une fraction d’éjection ventriculaire gauche réduite, indépendamment de la gravité de la SA.

      Conclusions

      Chez les patients présentant un SCA et une SA modérée ou sévère concomitante, la mortalité à long terme est comparablement élevée, indépendamment du type de SCA. La mortalité précoce élevée dans les cas de SA modérée ou sévère fait ressortir l’urgence d’agir en vue d’en limiter le risque.

      Graphical abstract

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Canadian Journal of Cardiology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Hasdai D.
        • Lev E.I.
        • Behar S.
        • et al.
        Acute coronary syndromes in patients with pre-existing moderate to severe valvular disease of the heart: lessons from the Euro-Heart Survey of acute coronary syndromes.
        Eur Heart J. 2003; 24: 623-629
        • Osnabrugge R.L.J.
        • Mylotte D.
        • Head S.J.
        • et al.
        Aortic stenosis in the elderly: disease prevalence and number of candidates for transcatheter aortic valve replacement: a meta-analysis and modeling study.
        J Am Coll Cardiol. 2013; 62: 1002-1012
        • Nkomo V.T.
        • Gardin J.M.
        • Skelton T.N.
        • et al.
        Burden of valvular heart diseases: a population-based study.
        Lancet. 2006; 368: 1005-1011
        • Paradis J.-M.
        • Fried J.
        • Nazif T.
        • et al.
        Aortic stenosis and coronary artery disease: What do we know? What don’t we know? A comprehensive review of the literature with proposed treatment algorithms.
        Eur Heart J. 2014; 35: 2069-2082
        • Stewart B.F.
        • Siscovick D.
        • Lind B.K.
        • et al.
        Clinical factors associated with calcific aortic valve disease. Cardiovascular Health Study.
        J Am Coll Cardiol. 1997; 29: 630-634
        • Hasdai D.
        • Topol E.J.
        • Califf R.M.
        • Berger P.B.
        • Holmes Jr., D.R.
        Cardiogenic shock complicating acute coronary syndromes.
        Lancet. 2000; 356: 749-756
        • Crimi G.
        • Montalto C.
        • Ferri L.A.
        • et al.
        Clinical impact of valvular heart disease in elderly patients admitted for acute coronary syndrome: insights from the Elderly-ACS 2 study.
        Can J Cardiol. 2020; 36: 1104-1111
        • O’Gara P.T.
        • Kushner F.G.
        • Ascheim D.D.
        • et al.
        2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.
        Circulation. 2013; 127: e362-e425
        • Amsterdam E.A.
        • Wenger N.K.
        • Brindis R.G.
        • et al.
        2014 AHA/ACC guideline for the management of patients with non-st-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
        J Am Coll Cardiol. 2014; 64: e139-e228
        • Collet J.-P.
        • Thiele H.
        • Barbato E.
        • et al.
        2020 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: the Task Force for the Management of Acute Coronary Syndromes in Patients Presenting Without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC).
        Eur Heart J. 2020; 42: 1289-1367
        • Singh G.K.
        • van der Bijl P.
        • Goedemans L.
        • et al.
        Prevalence of aortic valve stenosis in patients with ST-segment elevation myocardial infarction and effect on long-term outcome.
        Am J Cardiol. 2021; 153: 30-35
        • Tang L.
        • Gössl M.
        • Ahmed A.
        • et al.
        Contemporary reasons and clinical outcomes for patients with severe, symptomatic aortic stenosis not undergoing aortic valve replacement.
        Circ Cardiovasc Interv. 2018; 11e007220
        • Phua K.
        • Chew N.W.S.
        • Sim V.
        • et al.
        One-year outcomes of patients with ST-segment elevation myocardial infarction during the COVID-19 pandemic.
        J Thromb Thrombolysis. 2021; : 1-11
        • Chew N.W.
        • Sia C.H.
        • Wee H.L.
        • et al.
        Impact of the COVID-19 pandemic on door-to-balloon time for primary percutaneous coronary intervention—results from the Singapore Western STEMI Network.
        Circ J. 2021; 85: 139-149
        • Thygesen K.
        • Alpert J.S.
        • Jaffe A.S.
        • et al.
        Fourth universal definition of myocardial infarction (2018).
        Eur Heart J. 2018; 40: 237-269
        • Chew N.W.S.
        • Ngiam J.N.
        • Tan B.Y.
        • et al.
        Differences in clinical and echocardiographic profiles and outcomes of patients with atrial fibrillation versus sinus rhythm in medically managed severe aortic stenosis and preserved left ventricular ejection fraction.
        Heart Lung Circ. 2020; 29: 1773-1781
        • Chew N.W.S.
        • Ngiam J.N.
        • Tan B.Y.
        • et al.
        Inadequately low left ventricular mass in patients with significant aortic stenosis predicts favourable prognostic outcomes.
        Int J Cardiovasc Imaging. 2021; 37: 1611-1619
        • Ngiam J.N.
        • Chew N.W.S.
        • Pramotedham T.
        • et al.
        Low relative valve load is associated with paradoxical low-flow aortic stenosis despite preserved left ventricular ejection fraction and adverse clinical outcomes.
        Heart Lung Circ. 2022; 31: 128-135
        • Bonow R.O.
        • Carabello B.A.
        • Kanu C.
        • et al.
        ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): developed in collaboration with the Society of Cardiovascular Anesthesiologists: endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons.
        Circulation. 2006; 114: e84-e231
        • Vahanian A.
        • Baumgartner H.
        • Bax J.
        • et al.
        Guidelines on the management of valvular heart disease: the Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology.
        Eur Heart J. 2007; 28: 230-268
        • Lang R.M.
        • Badano L.P.
        • Mor-Avi V.
        • et al.
        Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging.
        J Am Soc Echocardiogr. 2015; 28: 1-39.e14
        • Charlson M.E.
        • Pompei P.
        • Ales K.L.
        • MacKenzie C.R.
        A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.
        J Chronic Dis. 1987; 40: 373-383
        • Baumgartner H.
        • Falk V.
        • Bax J.J.
        • et al.
        2017 ESC/EACTS guidelines for the management of valvular heart disease.
        Eur Heart J. 2017; 38: 2739-2791
        • Baumgartner H.C.
        • Hung J.C.-C.
        • Bermejo J.
        • et al.
        Recommendations on the echocardiographic assessment of aortic valve stenosis: a focused update from the European Association of Cardiovascular Imaging and the American Society of Echocardiography.
        Eur Heart J Cardiovasc Imaging. 2017; 18: 254-275
        • Ponikowski P.
        • Voors A.A.
        • Anker S.D.
        • et al.
        2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure: the Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure of the European Society of Cardiology (ESC) developed with the special contribution of the Heart Failure Association (HFA) of the ESC.
        Eur Heart J. 2016; 37: 2129-2200
        • Ahn J.-M.
        • Roh J.-H.
        • Kim Y.-H.
        • et al.
        Randomized trial of stents versus bypass surgery for left main coronary artery disease: 5-year outcomes of the PRECOMBAT study.
        J Am Coll Cardiol. 2015; 65: 2198-2206
        • Ngiam J.N.
        • Chew N.
        • Tan Y.B.
        • et al.
        An Asian perspective on gender differences in clinical outcomes and echocardiographic profiles of patients with medically managed severe aortic stenosis.
        Heart Lung Circ. 2021; 30: 115-120
        • Chew N.W.
        • Phua K.
        • Ho Y.J.
        • et al.
        Prognostic implications of bicuspid and tricuspid aortic valve phenotype on progression of moderate aortic stenosis and ascending aorta dilatation.
        Am J Cardiol. 2021; 161: 76-83
        • Chew N.W.
        • Kong G.
        • Ngiam J.N.
        • et al.
        Comparison of outcomes of asymptomatic moderate aortic stenosis with preserved left ventricular ejection fraction in patients ≥ 80 years versus 70-79 years versus < 70 years.
        Am J Cardiol. 2021; 157: 93-100
        • Strange G.
        • Stewart S.
        • Celermajer D.
        • et al.
        Poor long-term survival in patients with moderate aortic stenosis.
        J Am Coll Cardiol. 2019; 74: 1851-1863
        • Vahanian A.
        • Beyersdorf F.
        • Praz F.
        • et al.
        2021 ESC/EACTS guidelines for the management of valvular heart disease: developed by the Task Force for the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS).
        Eur Heart J. 2022; 43: 561-632
        • Otto C.M.
        • Nishimura R.A.
        • Bonow R.O.
        • et al.
        2020 ACC/AHA guideline for the management of patients with valvular heart disease: executive summary. A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.
        Circulation. 2021; 143: e35-e71
        • Badiani S.
        • Bhattacharyya S.
        • Aziminia N.
        • Treibel T.A.
        • Lloyd G.
        Moderate aortic stenosis: what is it and when should we intervene?.
        Interv Cardiol. 2021; 16: e09
        • Stassen J.
        • Ewe S.H.
        • Butcher S.C.
        • et al.
        Moderate aortic stenosis: importance of symptoms and left ventricular ejection fraction.
        Eur Heart J Cardiovasc Imaging. 2021; : jeab242
        • Neumann F.-J.
        • Sousa-Uva M.
        • Ahlsson A.
        • et al.
        2018 ESC/EACTS guidelines on myocardial revascularization.
        Eur Heart J. 2019; 40: 87-165

      Linked Article

      • Acute Coronary Syndrome and Aortic Stenosis: A Lethal Combo!
        Canadian Journal of CardiologyVol. 38Issue 8
        • Preview
          In this issue of the Canadian Journal of Cardiology, Chew and colleagues1 report on the outcomes of 563 patients with acute coronary syndrome (ACS) and aortic stenosis (AS), seen over a 10-year period. They demonstrate that approximately one-half of those with moderate or severe AS, and more than one-third of those with mild AS, died during follow-up, which averaged 2.5 years. Although these numbers are sobering, so too is the 30-day mortality of 17% for severe, 13% for moderate, and 6.4% for mild AS.
        • Full-Text
        • PDF