Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minn 55905, USA.
J Thorac Cardiovasc Surg. 2012 Dec;144(6):1421-7. doi: 10.1016/j.jtcvs.2011.09.075. Epub 2012 Feb 14.
To define the objective and subjective measures of aortic stenosis (AS) severity linked to survival after diagnosis in community practice.
All 360 Olmsted County, Minnesota residents (74 ± 14 years; 44% men) with AS diagnosed from 1988 to 1997 by echocardiography and without life-threatening comorbid conditions were enrolled. The presentation at first diagnosis, outcomes (mortality, heart failure, cardiac surgery), and coherence of guideline-based criteria for severe AS were analyzed.
The presentation was challenging. Cardiac symptoms were frequent (59%) and unassociated with the AS severity (all P > .13). Of the patients with severe AS, as determined by a valve area less than 1.0 cm(2), 67% had low gradient AS (≤40 mm Hg). An aortic valve area less than 1.0 cm(2) was the only objective measure independently determining survival (adjusted risk ratio, 1.81; 95% confidence interval [CI], 1.19-2.70; P < .01) and heart failure (adjusted risk ratio, 2.3; 95% CI, 1.3-4.0; P < .01), even in patients with low-gradient AS and/or an ejection fraction of 50% or greater. Excess mortality (vs expected mortality) occurred with an aortic valve area of less than 1.0 cm(2) (risk ratio, 1.78; 95% CI, 1.33-2.35; P < .001) even without symptoms (risk ratio, 1.65; 95% CI, 1.05-2.47; P = .02). Aortic valve replacement, ultimately performed in only 45% of those with an aortic valve area less than 1.0 cm(2), reduced mortality (risk ratio, 0.61; 95% CI, 0.39-0.94; P = .02) and heart failure (risk ratio, 0.29; 95% CI, 0.13-0.64; P < .01).
In community practice, AS affects elderly patients, and its presentation is challenging owing to the high frequency of low-gradient severe AS despite a normal ejection fraction and because symptoms are frequently not specific to AS. Consequently, aortic valve replacement is seldom performed despite its considerable benefit. Physicians should be aware that an aortic valve area of less than 1.0 cm(2) predicts for unfavorable outcomes, irrespective of symptoms or gradient. Thus, such patients should undergo a thorough evaluation to detect those who could benefit from aortic valve replacement, despite their challenging presentation.
定义与社区实践中诊断后生存相关的主动脉瓣狭窄（AS）严重程度的客观和主观测量指标。
所有 360 名明尼苏达州奥姆斯特德县（74±14 岁；44%为男性）居民，通过超声心动图诊断为 AS，且无危及生命的合并症。分析首次诊断时的表现、结局（死亡率、心力衰竭、心脏手术）以及基于指南的严重 AS 标准的一致性。
表现具有挑战性。心脏症状常见（59%），与 AS 严重程度无关（均 P>.13）。在瓣口面积小于 1.0cm²的重度 AS 患者中，67%为低梯度 AS（≤40mmHg）。瓣口面积小于 1.0cm²是唯一独立预测生存的客观指标（校正风险比，1.81；95%置信区间[CI]，1.19-2.70；P<.01）和心力衰竭（校正风险比，2.3；95%CI，1.3-4.0；P<.01），即使在低梯度 AS 和/或射血分数为 50%或更高的患者中也是如此。瓣口面积小于 1.0cm²时，死亡率（相对于预期死亡率）过高（风险比，1.78；95%CI，1.33-2.35；P<.001），即使没有症状（风险比，1.65；95%CI，1.05-2.47；P=.02）。最终仅对 45%的瓣口面积小于 1.0cm²的患者进行了主动脉瓣置换，降低了死亡率（风险比，0.61；95%CI，0.39-0.94；P=.02）和心力衰竭（风险比，0.29；95%CI，0.13-0.64；P<.01）。
在社区实践中，AS 影响老年患者，由于射血分数正常且症状常不特异于 AS，因此低梯度重度 AS 发生率较高，导致其表现具有挑战性。因此，尽管主动脉瓣置换具有显著获益，但很少进行该手术。医生应该意识到，瓣口面积小于 1.0cm²预测预后不良，与症状或梯度无关。因此，尽管患者表现具有挑战性，仍应进行全面评估以发现可能受益于主动脉瓣置换的患者。
