Hering Detlef, Piper Cornelia, Horstkotte Dieter
Department of Cardiology, Heart Center North Rhine-Westphalia, Ruhr University, Bad Oeynhausen, Germany.
J Heart Valve Dis. 2004 Mar;13(2):182-7.
Current guidelines recommend that aortic valve replacement (AVR) is deferred in asymptomatic patients with aortic stenosis until symptoms develop. Classical symptoms include exertional dyspnea, angina pectoris and syncope. The influence of atypical symptoms (dizziness, exertional intolerance, fatigue, palpitations/arrhythmias) and electrocardiographic signs of left ventricular hypertrophy or ST-segment/T-wave abnormalities on the natural course of the disease is unknown.
The clinical course of 100 patients with a preliminary diagnosis of asymptomatic aortic stenosis with respect to clinical signs and symptoms mentioned above was examined. All patients underwent serial echocardiographic examinations with calculation of aortic valve area by the continuity equation.
Two patients died during a mean follow up period of 34 +/- 32 months (range: 1-116 months). There were no peri- or postoperative deaths. Seven patients with hemodynamically severe aortic stenosis and concomitant atrial fibrillation, four with classical symptoms after re-evaluation, and five with left ventricular dysfunction underwent short-term AVR and were excluded from any subsequent analysis. In total, 84 patients were either entirely asymptomatic (n = 57; group A) or had atypical symptoms (n = 27; group B). Of these patients, 18 underwent AVR before onset of classical symptoms for various reasons, and 21 were treated medically. The remaining 15 group B patients exhibited classical symptoms significantly earlier than the remaining 30 group A patients (15 +/- 7 versus 35 +/- 24 months; p < 0.002). Aortic valve area tended to decrease more rapidly in group B patients than in group A patients (-0.16 +/- 0.12 versus -0.11 +/- 0.07 cm2 per year; p = 0.053). Clinical and hemodynamic progression were further increased if additional electrocardiographic abnormalities were present.
Both atypical symptoms and electrocardiographic signs of left ventricular hypertrophy/strain shorten the time interval until otherwise asymptomatic patients exhibit classical symptoms of advanced aortic stenosis requiring prosthetic valve replacement.
当前指南建议，对于无症状的主动脉瓣狭窄患者，在症状出现之前推迟进行主动脉瓣置换术（AVR）。典型症状包括劳力性呼吸困难、心绞痛和晕厥。非典型症状（头晕、劳力不耐受、疲劳、心悸/心律失常）以及左心室肥厚或ST段/T波异常的心电图表现对疾病自然病程的影响尚不清楚。
对100例初步诊断为无症状主动脉瓣狭窄的患者，就上述临床体征和症状进行了临床病程检查。所有患者均接受了系列超声心动图检查，并通过连续性方程计算主动脉瓣面积。
在平均34±32个月（范围：1 - 116个月）的随访期内，有2例患者死亡。无围手术期或术后死亡病例。7例血流动力学严重的主动脉瓣狭窄合并心房颤动患者、4例重新评估后出现典型症状的患者以及5例左心室功能不全患者接受了短期AVR，并被排除在后续分析之外。总共84例患者要么完全无症状（n = 57；A组），要么有非典型症状（n = 27；B组）。在这些患者中，18例因各种原因在典型症状出现之前接受了AVR，21例接受了药物治疗。其余15例B组患者出现典型症状的时间明显早于其余30例A组患者（15±7个月对35±24个月；p < 0.002）。B组患者的主动脉瓣面积下降速度往往比A组患者更快（每年-0.16±0.12对-0.11±0.07 cm²；p = 0.053）。如果存在额外的心电图异常，临床和血流动力学进展会进一步加快。
左心室肥厚/劳损的非典型症状和心电图表现均会缩短无症状患者出现需要人工瓣膜置换的晚期主动脉瓣狭窄典型症状的时间间隔。
