Angina pectoris and coronary artery disease in severe isolated valvular aortic stenosis.

BACKGROUND

Angina pectoris has long been recognised as one of the principal symptoms of severe aortic valve stenosis (AS), even in patients without significant coronary artery disease (CAD). However, controversy exists concerning the prevalence of angina pectoris and associated CAD in such patients.

OBJECTIVE

To determine the prevalence of CAD detectable by angiography and its relation to angina pectoris and coronary risk factors in patients with severe AS.

PATIENTS AND METHODS

All patients with symptomatic AS who had undergone aortic valve replacement and preoperative cardiac catheterisation at the Austin and Repatriation Medical Centre between 1 January 1986 and 31 May 1996 were retrospectively analysed. Those patients with multiple valve disease, aortic regurgitation of grade 2 or more in severity, or who had had prior coronary artery or valve surgery were excluded from this analysis.

RESULTS

A total of 328 consecutive patients with severe AS (242 men and 86 women; mean age 72 years, range 39-84 years) were studied. Significant CAD (reduction in luminal diameter > or = 50%) was found in 162 patients (49.4%). Typical angina was present in 74.7% of these 162 patients but it was also found in 44.6% of the 166 patients without obstructive CAD. Of the patients without angina (n = 133), 30.8% had significant CAD. By multivariate logistic regression, we have identified seven significant predictors for CAD among severe AS patients. Five factors increased risk. Expressed as odds ratio with 95% confidence interval, these included: (i) age in years (1.07; 1.04-1.11, P = 0.001); (ii) male gender (2.09; 1.14-3.80, P = 0.016); (iii) angina pectoris (3.19; 1.89-5.37, P < 0.001); (iv) history of myocardial infarction (2.87; 1.38-5.97, P = 0.005); and (v) peripheral vascular disease (2.28; 1.28-4.05, P = 0.005). Factors associated with decreased likelihood of CAD were serum high density lipoprotein (HDL) cholesterol (0.58; 0.34-0.71, P = 0.002) and peak systolic gradient across the aortic valve (0.97; 0.95-0.99, P = 0.0113).

CONCLUSION

Coronary arteriography can probably be omitted for a patient with severe AS if that patient has no symptoms of angina and has no risk factors known to increase its incidence.