Exercise Testing/Echocardiography in Asymptomatic AS
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1 Exercise Testing/Echocardiography in Asymptomatic AS Raluca Dulgheru, MD Heart Valve Clinic, University of Liège, CHU Sart Tilman, BELGIUM
2 Disclosure related to this presentation: None
3 VALVULAR HEART DISEASE Prevalence First valvular disease in Europe Severe AS Pooled prevalence in the elderly (>75 y) 3.4% (4.9 million pts in EU) 50% are asymptomatic
4 Management in severe AS - Surgery when symptoms develop - Asymptomatic patients matter of debate risk of sudden death risk of surgery risk of rapid progression risks related to the presence of a risk of irreversible myocardial prosthesis: damage hemorrhagic risk of shifting into a higher thrombotic surgical risk category prothesis dysfunction endocarditis Otto Circulation 1997, Rosenheck NEJM 2000, Pellika Circulation 2005
5 Management in asymptomatic severe AS - based on a risk stratification algorithm rest echocardiographic parameters (LVEF<50%, Vmax, Vmax progression, calcification +++, LVH, PHT, GLS, Zva, LA area etc ) exercise stress testing (exercise echocardiography) natriuretic peptides BNP/Nt-pro-BNP (rest and exercise) MDCT (Aortic Valve Calcium scoring) CMR (Mid-wall fibrosis) PET/CT (?) Otto Circulation 1997, Rosenheck NEJM 2000, Pellika Circulation 2005
6 Role of exercise testing/echocardiography for risk stratification in asymptomatic severe AS? Otto Circulation 1997, Rosenheck NEJM 2000, Pellika Circulation 2005
7 Prevalence of normal stress test Limiting symptoms in more than 1/3 Rafique et al. AJC, 2009
8 For unmasking symptoms in patients who claim to be asymptomatic
9 Risk Stratification with Exercise Testing 30 asymptomatic patients, age = 62±14 years, AVA = 0.7±0.2 cm², Peak Gradient = 79±21 mm Hg Negative test Positive test p< months Alborino D et al J Heart Valve D 2002; 11:204 Courtesy of dr. J Magne
10 Prognostic Value of Exercise Test in AS Meta-analysis: 7 studies, pts Risk for CV cardiac events events Sudden-death Risk n=9, of sudden 100% abnormal death (n=362) test OR: 0.12 ( ) p< OR: 0.18 ( ) p=0.05 Rafique et al. AJC, % of pts with abnormal stress test vs. 0%
11 For Individual Risk Stratification To aid to Clinical Decision Making and Guide the Type of Treatment
12 Indications for AVR in AV Stenosis ACC/AHA/ESC Practice Guidelines Asymptomatic pts with severe AS ACC/AHA (2008) Symptoms or Fall in SBP IIb C ESC (2012) if symptoms if fall in SBP I C IIa C
13 Indications for AVR in AV Stenosis ACC/AHA/ESC Practice Guidelines Asymptomatic pts with severe AS ACC/AHA (2014) Symptoms during exercise testing (I) Decreased exercise tolerance or Fall in SBP (IIa) ESC (2012) if symptoms if fall in SBP I IIa Physically active, <70yrs
14 Role of Exercise-testing in AS Predictive value for onset of spontaneous symptoms within 12 months (125 pts) Predictor NPV PPV Symptoms during exercise (p<0.001) (dizziness) whole population 87% 57% physically active, <70yrs 79% limited activity (> 70 yrs) 41% Abnormal BP response (p=ns) 78% 48% ST depression > 2mm (p=ns) 77% 45% Das, P. Eur Heart J 2005;26:
15 Outcome in Asymptomatic AS Normal Exercise Testing 150 Pts, asymptomatic, AVA<1.0 cm 2, LVEF>50%; Mean age: 69±8 y Lancellotti et al. JACC 59:235 43, 2012
16 Can exercise stress echocardiography help?
17 M 75 y, No RF Who is moderatly active AVA 0.65 cm² CASE 1 HR SBP (bpm) (mmhg) Rest No symptom Exer
18 REST EXERCISE E/E 11 E/E 16 PPG 79 MPG 48 AVA 0.65 cm² PSv 5.1 PPG 119 MPG 89 AVA 0.59 cm² PSv 7.9 EF 64 % EF 71 % Increase in mean pressure gradient = 41 mmhg
19 Exercise Echo in Asymptomatic AS n=69 asymptomatic severe AS with preserved LV ejection fraction n=26 abnormal exercise test Lancellotti, Piérard Circulation 2005;112:I 377-I 382
20 Exercise Echo in Asymptomatic AS Truly Asymptomatic Patients MPG + Test AVA Lancellotti et al Circulation 2005 Maréchaux et al, Eur H J 2010; 31,1390 Incremental prognostic value of Exercise Doppler Echo
21 REST EXERCISE CASE 2 EF 69.9% EF 70.7% F 83 y, Hypertension, Chol, AVA 0.53 cm² TTPG 22 mmhg MPG 74 mmhg AVA 0.53 cm² E/E 22.4 MPG 106 mmhg AVA 0.42 cm² TTPG 68 mmhg E/E 35.5 HR SBP (bpm) (mmhg) Rest Exer No dyspnea+chest pain Stop for leg discomfort Few VES
22 PREDICTORS OF AN ABNORMAL EXERCISE RESPONSE 0R MPG diff Ejection Fraction diff Lancellotti et al Eur J Echo 2008;9:338 p 50 pts with AS <1 cm² Semi-supine exercise test 48% developed symptoms Maréchaux et al Echocardio 2007;24:955
23 A Year Later: ECHO IN Decrease in daily activities Exercise intolerance BNP : 636 pg/ml
24 MPG 81 mmhg AVA 0.44 cm² TTPG 43 mmhg E/E 68
25 IMPAIRED LONGITUDINAL FUNCTION 17% % in 2008
26 Magne et al. Abstr EACVI, 2014 Courtesy of dr. J Magne
27 Magne et al. Abstr EACVI, 2014 Courtesy of dr. J Magne
28 Magne et al. Abstr EACVI, 2014 Courtesy of dr. J Magne
29 Exercise-induced changes in SPAP Consecutive asymptomatic patients (n=105) with severe AS (AVA<1cm²), preserved LV systolic function (LVEF >55%), normal exercise test Systolic PAP, mmhg p< ±8 Rest 62±1 6 Exercise Prevalence of PHT, % p< % (n=6) Rest 55% (n=58) Exercise Lancellotti et al. Circulation, 2012 ( 50mmHg) ( 60mmHg)
30 Cardiac Event-free Survival according to Ex-PHT Cardiac Event-free Survival, % ±6% 59±8% 65±6% 55±9% 43±7% p= ±7% Follow-up, months 12% of cardiovascular death in Ex-PHT group (vs. 0%) No Ex-PHT Ex-PHT Lancellotti al. Circulation, 2012
31 Indications for aortic valve replacement in asymptomatic aortic stenosis AVR is indicated in asymptomatic patients with severe AS and systolic LV dysfunction (LVEF < 50%) not due to another cause. AVR is indicated in asymptomatic patients with severe AS and abnormal exercise test showing symptoms on exercise clearly related to AS. AVR should be considered in asymptomatic patients, with normal EF and none of the above mentioned exercise test abnormalities, if the surgical risk is low, and one or more of the following findings is present: very severe AS defined by a peak transvalvular velocity > 5.5 m/s, severe valve calcification and a rate of peak of transvalvular velocity progression 0.3 m/s per year. AVR may be considered in asymptomatic patients with severe AS, normal EF and none of the above mentioned exercise test abnormalities, if surgical risk is low, and one or more of the following findings is present: markedly elevated natriuretic peptide levels confirmed by repeated measurements without other explanations, increase of mean pressure gradient with exercise by > 20 mmhg, excessive LV hypertrophy in the absence of hypertension. Class I I IIa IIb Level C C C C European Heart Journal doi: /eurheartj/ehs109 & European Journal of Cardio-Thoracic Surgery doi: /ejctsezs455).
32
33 Factors Highlighted by Exercise Test (Echo) Symptoms LV Dysfunction LV geometry LV Function Severity of VHD PAsP Changes BNP changes Risk Stratification/Outcome Prediction Optimal Timing of Surgery
34
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