Ersboll Mads, Schulte Phillip J, Al Enezi Fawaz, Shaw Linda, Køber Lars, Kisslo Joseph, Siddiqui Irfan, Piccini Jonathan, Glower Donald, Harrison J Kevin, Bashore Thomas, Risum Niels, Jollis James G, Velazquez Eric J, Samad Zainab
Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina; The Heart Center, Department of Cardiology, University of Copenhagen, Rigshospitalet, Denmark.
The Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina.
Am J Cardiol. 2015 Jan 1;115(1):86-92. doi: 10.1016/j.amjcard.2014.09.049. Epub 2014 Oct 14.
We aimed to characterize the hemodynamic progression of aortic stenosis (AS) in a contemporary unselected cohort of patients with preserved left ventricular ejection fraction. Current guidelines recommend echocardiographic surveillance of hemodynamic progression. However, limited data exist on the expected rate of progression and whether clinical variables are associated with accelerated progression in contemporarily managed patients with AS. We conducted a retrospective analysis of patients presenting with AS and explored the trajectory of AS mean gradient over time using generalized estimating equations and fit a longitudinal linear regression model with adjustment for baseline clinical variables. A total of 1,558 patients (median age 72; interquartile range 65 to 79) having mild (n = 982), moderate (n = 363), or severe AS (n = 213) were included. In patients with mild AS at baseline (n = 983), 303 (31%) had progressed to moderate/severe AS/AVR within 5 years of the index echo. In patients with moderate AS, 159 of 363 (44%) had progressed to severe AS/AVR within 2 years of the index echo. The annual change in mean gradient was dependent on baseline AS severity. Average annual increases in mean gradient were 6.8% (95% confidence interval 6.0 to 7.6) and 7.1% (95% confidence interval 4.8 to 9.3) in patients with mild and moderate AS, respectively. In the subset of patients with mild AS at baseline, age (p = 0.0310) and gender (p = 0.0270) had significant interaction with change in mean gradient over time. In patients with moderate AS, age (p <0.0001), gender (p = 0.0346), renal dysfunction (p = 0.0036), and hyperlipidemia (p = 0.0010) demonstrated significant interaction with change in mean gradient over time. In conclusion, although average disease progression was slower than previously reported, a significant proportion of patients with mild and moderate AS progressed to higher grades within the currently recommended time windows for echocardiographic follow-up.
我们旨在描述当代未经选择的左心室射血分数保留的主动脉瓣狭窄（AS）患者的血流动力学进展情况。当前指南推荐对血流动力学进展进行超声心动图监测。然而，关于当代接受治疗的AS患者的预期进展速度以及临床变量是否与加速进展相关的数据有限。我们对AS患者进行了回顾性分析，并使用广义估计方程探讨了AS平均梯度随时间的变化轨迹，并拟合了一个对基线临床变量进行调整的纵向线性回归模型。共纳入1558例患者（中位年龄72岁；四分位间距65至79岁），其中轻度AS患者982例、中度AS患者363例、重度AS患者213例。在基线时为轻度AS的患者（n = 983）中，303例（31%）在首次超声心动图检查后的5年内进展为中度/重度AS/主动脉瓣置换术（AVR）。在中度AS患者中，363例中有159例（44%）在首次超声心动图检查后的2年内进展为重度AS/AVR。平均梯度的年度变化取决于基线AS严重程度。轻度和中度AS患者的平均梯度平均每年分别增加6.8%（95%置信区间6.0至7.6）和7.1%（95%置信区间4.8至9.3）。在基线时为轻度AS的患者亚组中，年龄（p = 0.0310）和性别（p = 0.0270）与平均梯度随时间的变化有显著交互作用。在中度AS患者中，年龄（p <0.0001）、性别（p = 0.0346）、肾功能不全（p = 0.0036）和高脂血症（p = 0.0010）与平均梯度随时间的变化有显著交互作用。总之，尽管平均疾病进展比先前报道的要慢，但相当一部分轻度和中度AS患者在目前推荐的超声心动图随访时间窗内进展到更高等级。
