CARDIAC PHYSIOLOGIST LED AORTIC STENOSIS SURVEILLANCE CLINIC

Transcription

1 CARDIAC PHYSIOLOGIST LED AORTIC STENOSIS SURVEILLANCE CLINIC

2 Background Aortic stenosis is the commonest form of valvular heart disease in the UK Asymptomatic patients with mild AS make up a significant proportion of patients followed up in the general cardiology clinics

3 Epidemiology Aortic sclerosis is present in about 25% of adults over the age of 65 years. Progression to severe aortic stenosis within 7 years in 16% of patients of patients Otto 2003;25(3): European 190.European Heart Journal Prevalance of aortic valve abnormalities in the elderly-an echocardiographic study of a random population sample Number of patients-560 Mild calcification found in 222(40%) Severe calcification found in 72(13%) Critical native aortic valve disease in 12(2.2%) CONCLUSION: Calcific aortic valve stenosis constitutes a significant health problem J Am Coll Cardiol.1993 Apr;21(5):1220-5

4 Why monitor AS? The rate of progression from mild to severe AS varies between patients and regular echocardiographic assessment is essential in this group of patients. The average increase in mean gradient is 7 mm Hg per year. The mean decrease in valve area ranges from 0.02 cm² per year in slow progressors to 0.3 cm² per year in fast progressors.

5 Establishing an ASSC AS surveillance clinic established in May 2003 (JRD( JRD s idea - no known model available) - to reduce the burden of follow-up patients in general cardiology clinics - to standardise the echocardiographic assessment of patients with mild AS

6 Practicalities Initial assessment by a cardiologist. Baseline transthoracic echocardiogram. Letter to GP that patient enrolled into ASSC. ENTRY CRITERIA: Asymptomatic Peak aortic valve gradient (AVG) of less than 50 mmhg Normal internal left ventricular dimensions and systolic function

7 Echocardiographic Assessment by BSE Accredited Cardiac Physiologist/Sonographer Peak AVG (2 or more views) Traced mean gradient LV dimensions and systolic function AVA by continuity equation (and planimetry when possible) No symptomatic assessment but patients reminded to inform GP of any new cardiac symptoms Endocarditis prophylaxis advice

8 Outcomes / progress so far. 180 patients (age range of 25 and 84 years). First 100 patients reported at BSE (BSE 2005): average peak AVG 38.9mmHg (± SD19.1), average AV area (derived by continuity equation) of 1.29cm 2 (± SD 0.46). 12 patients referred back to their cardiologist due to worsening echocardiographic parameters (AVG >50mmHg) 2 cases of coarctation diagnosed 2 patients found to have normal aortic valves with small LVOT gradients 3 valve replacements 2 unrelated deaths No complaints.

9 Summary The establishment of an AV surveillance clinic has led to a reduction in number of patients requiring follow-up by a cardiologist whilst also standardising the echocardiographic assessment. We believe that this system is more clinically efficient and is also likely to be cost- effective. The clinic highlights the important potential clinical role of a Consultant Sonographer.

10 Thank you Diolch

11 Back-up slides

12 Clinical background In 1854 William Stokes described in his textbook, The diseases of the heart and the aorta,, specific pathological descriptions of calcific aortic valve disease, including: (1) permanent patency of the valve in which the diameter may be increased or diminished (2) an extreme ossific growth along the valve surrounding the ventricle, at which the valves are often destroyed (3) an atheromatous deposit on the ventricular surface of the valve which is often seen in the context of fatty degeneration of the heart.

13 Aetiologies of calcific aortic stenosis egenerative ndocarditis yperuricaemia abry s disease flammatory: econdary to chronic fection ardiac valve mours Bicuspid valve Gaucher Calciphylaxis Drug induced Paget s disease Homozygous type II Incontinentii pigmentii Rheumatic Hyperparathyroidism Hypercholesterolaemia Carcinoid heart diseases Pseudoxanthoma elasticum Congenital HLA B27 valvulitis