Background
Methods
Study population
Clinical evaluation
Echocardiography
Outcome measures
Data analysis
Results
Baseline clinical, hemodynamic and echocardiographic characteristics
80–84 years | 85–89 years | ≥90 years | p for trenda
| |
---|---|---|---|---|
Participants, n | 323 | 183 | 50 | |
Male, n (%) | 125 (39 %) | 68 (37 %) | 13 (27 %) | |
Mitral stenosis, n (%) | 10 (53 %) | 6 (3 %) | 3 (6 %) | |
Mild, n (%) | 5 (2 %) | 3 (2 %) | 1 (2 %) | 0.85 |
Moderate, n (%) | 4 (1 %) | 3 (2 %) | 2 (4 %) | 0.28 |
Severe, n (%) | 1 (0.3 %) | 0 (0 %) | 0 (0 %) | 0.41 |
Mitral regurgitation, n (%) | 236 (73 %) | 140 (77 %) | 39 (78 %) | |
Mild, n (%) | 234 (72 %) | 138 (75 %) | 39 (78 %) | 0.32 |
Moderate, n (%) | 2 (1 %) | 2 (1 %) | 0 (0 %) | 0.89 |
Aortic stenosis, n (%) | 63 (20 %) | 45 (25 %) | 19 (38 %) | |
Mild, n (%) | 27 (8 %) | 7 (4 %) | 1 (2 %) | 0.016 |
Moderate, n (%) | 24 (7 %) | 15 (8 %) | 9 (18 %) | 0.10 |
Severe, n (%) | 12 (4 %) | 11 (6 %) | 9 (18 %) | 0.002 |
Aortic regurgitation, n (%) | 118 (37 %) | 72 (39 %) | 25 (50 %) | |
Mild, n (%) | 113 (35.4) | 69 (37.9) | 24 (48.0) | 0.15 |
Moderate, n (%) | 5 (1.6) | 3 (1.6) | 1 (2.0) | 0.85 |
No VHD (n = 92) | Mild VHD (n = 367) | Moderate-to-severe VHD (n = 97) |
p value | |
---|---|---|---|---|
Socio-demographic characteristics | ||||
Male, n (%) | 38 (41 %) | 135 (37 %) | 33 (34 %) | <0.001 |
Age, (years) | 84.1 ± 2.9 | 84.6 ± 3.6 | 86.3 ± 4.3 | 0.58 |
Coronary risk factors and multimorbidity | ||||
Smoking (current or ex), n (%) | 31 (34 %) | 122 (33 %) | 22 (23 %) | 0.11 |
Hypertension, n (%) | 60 (66 %) | 258 (70 %) | 72 (74 %) | 0.46 |
Dyslipidemia, n (%) | 40 (45 %) | 165 (46 %) | 37 (39 %) | 0.46 |
Type 2 diabetes, n (%) | 21 (23 %) | 62 (17 %) | 19 (20 %) | 0.38 |
CIRS, median (IQR) | 4 (3–5) | 3 (3–5) | 4 (3–6) | 0.008 |
Prior history | ||||
Myocardial infarction, n (%) | 17 (19 %) | 35 (10 %) | 8 (8 %) | 0.029 |
TIA or stroke, n (%) | 15 (16 %) | 57 (16 %) | 29 (30 %) | 0.025 |
COPD, n (%) | 13 (12 %) | 40 (11 %) | 10 (10 %) | 0.79 |
Peripheral arterial disease, n (%) | 10 (11 %) | 29 (8 %) | 11 (11 %) | 0.45 |
CABG, n (%) | 8 (9 %) | 20 (5 %) | 8 (8 %) | 0.39 |
PCI, n (%) | 12 (13 %) | 30 (8 %) | 5 (5 %) | 0.13 |
Valvular surgery, n (%) | 2 (2 %) | 15 (4 %) | 2 (2 %) | 0.48 |
Heart failure, n (%) | 8 (9 %) | 36 (10 %) | 16 (16 %) | 0.14 |
Chronic atrial fibrillation, n (%) | 4 (4 %) | 34 (9 %) | 19 (20 %) | 0.002 |
Pacemaker, n (%) | 5 (6 %) | 21 (6 %) | 5 (5 %) | 0.97 |
Symptoms | ||||
Angina pectoris, n (%) | 11 (12 %) | 58 (16 %) | 21 (22 %) | 0.20 |
Dyspnea ≥ 3a, n (%) | 22 (24 %) | 101 (28 %) | 42 (43 %) | 0.005 |
Peripheral edema, n (%) | 31 (34 %) | 115 (31 %) | 42 (43 %) | 0.090 |
Fatigue, n (%) | 17 (19 %) | 75 (21 %) | 22 (23 %) | 0.80 |
Cardiac medications | ||||
Diuretics, n (%) | 45 (49 %) | 162 (44 %) | 54 (56 %) | 0.12 |
Potassium-sparing agents, n (%) | 17 (18 %) | 53 (14 %) | 17 (18 %) | 0.54 |
ACE inhibitors, n (%) | 20 (22 %) | 123 (28 %) | 29 (30 %) | 0.39 |
ARBs, n (%) | 18 (20 %) | 51 (14 %) | 17 (18 %) | 0.34 |
ß-blockers, n (%) | 28 (30 %) | 161 (44 %) | 46 (47 %) | 0.035 |
Digitalis, n (%) | 0 (0 %) | 11 (3 %) | 11 (11 %) | <0.001 |
Physical activity and cognitive functioning | ||||
ADL, median (IQR) | 25 (21–27) | 25 (21–28) | 23 (17–27) | <0.001 |
MMSE, median (IQR) | 28 (26–29) | 28 (26–29) | 28 (25–29) | 0.36 |
GDS-15, median (IQR) | 2 (1–4) | 2 (1–4) | 3 (2–5) | 0.033 |
No VHD (n = 92) | Mild VHD (n = 367) | Moderate-to-severe VHD (n = 97) |
p value | |
---|---|---|---|---|
LV morphology and function | ||||
LVEF (%) | 55 ± 3 | 55 ± 5 | 55 ± 3 | 0.60 |
LVEF < 50 %, n (%) | 4 (4 %) | 26 (7 %) | 2 (2 %) | 0.14 |
LV mass (g/m2) | 86 ± 21 | 92 ± 23 | 98 ± 27 | 0.002 |
LVH, n (%) | 10 (11 %) | 57 (16 %) | 18 (19 %) | 0.33 |
Indexed LAV (mL/m2) | 30 ± 9 | 32 ± 10 | 39 ± 12 | <0.001 |
Indexed LAV > 34 mL/m2, n (%) | 23 (25 %) | 145 (40 %) | 62 (65 %) | <0.001 |
Stroke volume (mL/beat) | 68 ± 19 | 70 ± 16 | 68 ± 14 | 0.48 |
RWMA, n (%) | 13 (14 %) | 43 (12 %) | 7 (7 %) | 0.30 |
LV diastolic filling | ||||
E/A ratio | 0.87 ± 0.44 | 0.92 ± 0.48 | 1.07 ± 0.58 | 0.027 |
E/A ratio ≥ 1.5, n (%) | 6 (7 %) | 31 (9 %) | 14 (19 %) | 0.013 |
E/e’ ratio | 10.7 ± 3.1 | 11.6 ± 4.0 | 13.5 ± 4.2 | <0.001 |
E/e’ ratio ≥ 13, n (%) | 23 (25 %) | 102 (28 %) | 41 (53 %) | <0.001 |
Deceleration time (ms) | 178 ± 41 | 178 ± 44 | 174 ± 51 | 0.74 |
Deceleration time < 160 ms, n (%) | 29 (32 %) | 115 (32 %) | 35 (48 %) | 0.028 |
Vp (cm/s) | 58 ± 17 | 56 ± 16 | 52 ± 22 | 0.12 |
Vp < 45 cm/s, n (%) | 23 (25 %) | 114 (32 %) | 35 (48 %) | 0.006 |
Clinical outcomes
Predictors of all-cause and cardiovascular mortality
Univariable | Multivariable | |||||
---|---|---|---|---|---|---|
HR | 95 % CI |
p value | HR | 95 % CI |
p value | |
All-cause mortality | ||||||
Age (year) | 1.10 | 1.07–1.14 | <0.001 | 1.09 | 1.05–1.12 | <0.001 |
Dyspnea ≥3 | 2.29 | 1.77–2.97 | <0.001 | 1.81 | 1.37–2.39 | <0.001 |
CIRS (per point increase) | 1.21 | 1.12–1.30 | <0.001 | 1.11 | 1.03–1.21 | 0.007 |
Moderate-to-severe VHD | 1.91 | 1.42–2.58 | <0.001 | 1.42 | 1.04–1.95 | 0.029 |
Moderate-to-severe AS | 1.96 | 1.42–2.70 | <0.001 | |||
LAVI ≥34 mL/m2
| 1.58 | 1.22–2.04 | 0.001 | |||
LV hypertrophy | 1.01 | 1.00–1.01 | 0.004 | 1.01 | 1.00–1.01 | 0.020 |
Moderate-to-severe MS | 2.30 | 1.08–4.88 | 0.030 | |||
LVEF ≤50 % | 1.63 | 1.02–2.61 | 0.040 | 1.66 | 1.03–2.67 | 0.037 |
Dyslipidemia | 0.78 | 0.60–1.01 | 0.063 | |||
Cardiovascular mortality | ||||||
Age (year) | 1.09 | 1.04–1.14 | <0.001 | 1.06 | 1.01–1.11 | 0.014 |
CIRS (per point increase) | 1.23 | 1.10–1.37 | <0.001 | |||
Dyspnea ≥3 | 3.06 | 2.07–4.53 | <0.001 | 2.68 | 1.80–3.98 | <0.001 |
Moderate-to-severe VHD | 2.88 | 1.90–4.37 | <0.001 | 2.13 | 1.38–3.29 | 0.001 |
Moderate-to-severe AS | 3.06 | 1.99–4.72 | <0.001 | |||
Moderate-to-severe MS | 4.65 | 2.03–10.63 | <0.001 | |||
LAVI ≥34 mL/m2
| 1.87 | 1.27–2.77 | 0.002 | |||
LV hypertrophy | 1.01 | 1.00–1.02 | 0.029 | 1.01 | 1.00–1.01 | 0.087 |
First unplanned Hospitalization | ||||||
Smoker (current or ex) | 1.60 | 1.25–2.04 | <0.001 | 1.69 | 1.32–2.16 | <0.001 |
CIRS (per point increase) | 1.20 | 1.13–1.29 | <0.001 | 1.15 | 1.07–1.23 | <0.001 |
Dyspnea ≥3 | 1.81 | 1.42–2.31 | <0.001 | 1.50 | 1.16–1.94 | 0.002 |
Moderate-to-severe AS | 1.71 | 1.25–2.33 | 0.001 | |||
LAVI ≥34 mL/m2
| 1.37 | 1.08–1.74 | 0.009 | |||
Moderate-to-severe VHD | 1.51 | 1.13–2.03 | 0.006 | 1.43 | 1.06–1.94 | 0.021 |
Age (year) | 1.03 | 1.00–1.06 | 0.041 |
Predictors of first unplanned hospitalizations
Discussion
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The prevalence of moderate-to-severe VHD in very old subjects is around 17 %, and is similar in men and women.
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There is a significant age-related increase in both the prevalence and the severity of aortic stenosis.
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Higher rates of heart failure, atrial fibrillation and stroke were found in subjects with moderate-to-severe VHD than in those without. Accordingly, physical activity and cognitive functioning was negatively affected in patients with moderate-to-severe VHD.
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The presence of moderate-to-severe VHD independently increases overall and cardiovascular mortality risks, as well as the need for unplanned hospitalizations.