Aortic Stenosis in the Elderly: Difficulties for the Clinician. Are Symptoms Due to Aortic Stenosis?

Transcription

1 Aortic Stenosis in the Elderly: Difficulties for the Clinician Are Symptoms Due to Aortic Stenosis? Raphael Rosenhek Department of Cardiology Medical University of Vienna No disclosure European Society of Cardiology 2011 Paris, August 31st 2011

2 Prevalence of moderate or severe AS (%) Valvular Heart Disease Prevalence Proportion of the population aged 0-14 and 65 years EU-27 (% of total population) Population based studies Projection Nkomo V et al. Lancet 2006;368: Eurostat 2010

3 Aortic Stenosis Symptom: Definition A subjective indication of a disorder or disease, such as pain, nausea, or weakness. The American Heritage Medical Dictionary Copyright 2007, 2004 by Houghton Mifflin Company [Etymology: Gk, symptoma, that which happens A subjective indication of a disease or a change in condition as perceived by the patient. Many symptoms are accompanied by objective signs. Some symptoms may be objectively confirmed. Mosby's Medical Dictionary, 8th edition. 2009, Elsevier

4 Survival (%) Severe Aortic Stenosis Prognosis of Symptomatic Patients Latent period (increasing obstruction, Myocardial overload) Onset of severe symptoms failure syncope angina Average survival (yrs) 20 0 Average age of death Age (yrs) Ross, Braunwald. Circulation 1968

5 Event-free Survival Asymptomatic Severe Aortic Stenosis 1,0 0,8 0,6 0,4 Exercise-testing Negative (22 patients) Positive test: symptoms (n=23) BP increase < 20mmHg ST segment depression > 2mm Complex vent. arrhyth. 0,2 0 Positive (44 patients) P= n= Time (months) Amato, MC. Heart 2001;86:

6 Severe Aortic Stenosis Exercise-testing Predictive value for onset of spontaneous symptoms within 12 mths n = 125 Predictor NPV PPV Symptoms during exercise 87% 57% physically active, <70yrs 79% Abnormal BP response 78% 48% ST depression > 2mm 77% 45% Das, P. Eur Heart J 2005;26:

7 Aortic Stenosis with Surgical Indication Undertreatment 59% 43% 68% 67% 43% 70% 40% 62% 48% AVR No AVR 41% 57% 32% 33% 57% 30% 60% 38% 52% Bouma 1999 Bouma 2004 Iung 2003* Iung 2005 Van Geldorp 2009 EU Pellikka 2005 Charlson 2006 Bach 2007 Bach 2009 US EU: Bouma BJ, Heart Bouma BJ, JHVD Iung B, EHJ Iung B, EHJ Van Geldorp MW, EJCTS US: Pellikka PA, Circ Charlson E, JHVD Bach DS, JACC Bach DS, CDQO 2009.

8 Aortic Stenosis Undertreatment EU Aortic stenosis 75 yrs n = 408 No severe AS (n = 124) Severe AS (n = 284) No severe symptoms n = 68 No intervention n = 72 (33%) Severe symptoms n = 216 Intervention n = 144 (67%) NYHA III: 105 NYHA IV: 35 Angina: 147 Iung, B et al. Eur Heart J 2005;26:

9 Aortic Valve Disease - Euroheart Survey Why are patients denied Surgery? Age Iung, B. et al. Eur Heart J :

10 Aortic Valve Disease - Euroheart Survey Why are patients denied Surgery? Iung, B. et al. Eur Heart J :

11 Aortic Valve Disease - Euroheart Survey Why are patients denied Surgery? LVEF Iung, B. et al. Eur Heart J :

12 Aortic Stenosis Undertreatment US 155 patients with severe AS 75 No-AVR 80 AVR 53 Symptoms 22 No symptoms Operative Risk (Average 11.5%) <5% 25 5< to 10% 9 >10% 19 Exercise testing 1 of died from complications related to AS within 14 months Bach, DS et al. J Am Coll Cardiol 2007;50:

13 Aortic Stenosis Reasons for not Performing Surgery 369 patients with severe AS 191 No-AVR 178 AVR 126 symptoms (33% of total) 65 Asymptomatic Reasons for not performing AVR 48%: High Surgical Risk 19%: Symptoms unrelated to AS 19%: Patient Refusal 14%: Other Bach DS, et al. Circ Cardiovasc Qual Outcomes 2009;2:

14 PARTNER Cohort B Patient Characteristics TAVI n = 179 Standard Therapy n = 179 P Value Age (yr) 83.1 ± ± Male sex (%) STS Score 11.2 ± ± Logistic EuroSCORE 26.4 ± ± NYHA I or II (%) III or IV (%) CAD (%) Prior MI (%) Prior CABG (%) Prior PCI (%) Prior BAV (%) CVD (%) Leon MB et al. N Engl J Med 2010 ;363:

15 PARTNER Cohort B Comorbidities Characteristic TAVI n = 179 Standard Therapy n = 179 P Value Peripheral valve disease (%) Chronic obstructive pulmonary disease Any (%) O 2 -dependent (%) Creatinine > 2 mg/dl (%) Atrial fibrillation (%) Permanent pacemaker (%) Pulmonary hypertension (%) Frailty (%) Porcelain aorta (%) Chest wall irradiation (%) Chest wall deformity (%) Liver disease (%) Leon MB et al. N Engl J Med 2010 ;363:

16 All-Cause Mortality, % 100 PARTNER Trial All-Cause Mortality All-Cause Mortality Standard Therapy TAVI 80 at 1 yr = 20.0% NNT = 5.0 pts % Numbers at Risk 30.7% Months HR [95% CI] = 0.55 [0.40, 0.74] P (log rank) <.001 TAVI Standard Therapy Leon MB et al. N Engl J Med 2010 ;363:

17 Patients Surviving, % 100 PARTNER B Trial Evolution of Symptoms (NYHA) in Survivors NYHA Over Time in Surviving Patients P =.68 P <.001 P <.001 P < TAVI Standard TAVI Standard TAVI Standard TAVI Standard Therapy Therapy Therapy Therapy Baseline 30 Days 6 Months 1 Year I II III IV Leon MB et al. N Engl J Med 2010 ;363:

18 PARTNER A Trial Evolution of Symptoms Leon MB et al. N Engl J Med 2010 ;363:

19 SOURCE Registry (TAVI) Cause of Late Deaths (30 days to 1 year) n=179/1038 Thomas M et al. Circulation 2011;124:

20 Severe Aortic Stenosis Neurohormones Lim, P et al. Eur Heart J 2004;25: Gerber, P et al. Circulation 2003;107:

21 Biomarkers in Valvular Heart Disease Symptomatic Aortic Stenosis - conservative ttment Nessmith M et al. Am J Cardiol 2005;96:

22 Event-free Survival (%) The Spectrum of Aortic Stenosis Peak Aortic Jet Velocity AV-Vel 2.5 to 3.0 m/s AV-Vel 3.0 to 4.0 m/s AV-Vel 4.0 to 5.0 m/s AV-Vel 5.0 to 5.5 m/s P < AV-Vel 5.5 m/s Years Rosenhek R et al. Eur Heart J 2004;25: Rosenhek R et al. N Engl J Med 2000;343: Rosenhek R et al. Circulation 2010;121:

23 Decision-Making The High-Risk Patient Individualized Risk Assessment* Patient Preferences* Natural Disease History* Risk of Intervention* Long-term postprocedural outcome* Risk Scores? Life Expectancy* * Influence of symptoms Timing and Choice of Procedure Team Approach Adapted from ESC Working Group on Valvular Heart Disease Position Paper. Assessing the Risk of Interventions in Patients with Valvular Heart Disease Eur Heart J 2011

24 Life Expectancy in Years Europe and US EU US Age Overall Men Women Overall Men Women Eurostat. European Commission. Life Expectancy by Sex and Age. Queries for Survival performed for the year 2007 for the European Union (27 countries) U.S. National Center for Health Statistics, National Vital Statistics Reports (NVSR), U.S. Decennial Life Tables for , United States Life Tables, Volume 57, Number 1, August 5, Rosenhek, R. et al., Eur Heart J 2011 ESC Working Group on Valvular Heart Disease Position Paper. Assessing the Risk of Interventions in Patients with Valvular Heart Disease

25 Are Symptoms Due to AS Summary Per definition, symptoms relate to subjective patient perception Objectivation may be particularly challenging in elderly patients In this patient subset, mild symptoms may be unspecific and unrelated to AS In selected patients, even advanced symptoms may be unrelated to AS Considering the dynamics of symptoms and additional risk stratification may be helpful BNP Aortic jet velocity Left ventricular function Decision-making in elderly (high-risk) patients should be performed as part of an integrated approach, which includes: complete multidisciplinary clinical evaluation the natural history of the disease reference to local resources and surgical results the preferences of the patient and their family

26 One only sees well with the heart. The essential is invisible for the eyes The Little Prince

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