Tribouilloy Christophe, Bohbot Yohann, Maréchaux Sylvestre, Debry Nicolas, Delpierre Quentin, Peltier Marcel, Diouf Momar, Slama Michel, Messika-Zeitoun David, Rusinaru Dan
From the Department of Cardiology (C.T., Y.B., Q.D., M.P., D.R.), Division of Clinical Research and Innovation (M.D.), and Intensive Care Unit, Department of Nephrology (M.S.), University Hospital Amiens, France; INSERM U-1088, Jules Verne University of Picardie, Amiens, France (C.T., S.M., M.S., D.R.); Groupement des Hôpitaux de l'Institut Catholique de Lille/Faculté libre de médecine, Université Lille Nord de France (S.M.); Department of Cardiology, Centre Hospitalier Universitaire de Lille, F-59000, France (N.D.) and Department of Cardiology, Cardiovascular Division, AP-HP, Bichat Hospital, Paris, France (D.M.-Z.).
Circ Cardiovasc Imaging. 2016 Nov;9(11). doi: 10.1161/CIRCIMAGING.116.005121.
BACKGROUND: Current guidelines define severe aortic stenosis in patients with aortic valve area normalized to body surface area (AVA/BSA) <0.6 cm/m; yet, this cutoff has never been validated. Moreover, it is not known whether AVA normalization to other body size indexes allows improved outcome prediction. We aim to test the value of AVA normalized to body size for outcome prediction in asymptomatic aortic stenosis. METHODS AND RESULTS: We included 289 patients with asymptomatic aortic stenosis, preserved ejection fraction, and AVA<1.3 cm at diagnosis. The outcome measure was the occurrence of aortic valve replacement or all-cause death or during follow-up. AVA was normalized to BSA, height, weight, and body mass index. For each normalized index, patients in the lowest tertile were at high risk of events whereas outcome was similar for the other tertiles. High risk of events was observed with AVA/BSA <0.4 cm/m (adjusted hazard ratio [HR], 3.42 [2.09-5.60]), AVA/height <0.45 cm/m (adjusted HR, 3.99 [2.42-6.60]), AVA/weight <0.01 cm/kg (adjusted HR, 3.37 [2.07-5.49]), and AVA/body mass index <0.029 cm/kg per meter square (adjusted HR, 3.23 [1.99-5.24]). Mortality risk was high with AVA/height <0.45 cm/m (adjusted HR, 2.18 [1.28-3.71]), followed by AVA/BSA <0.40 cm/m (adjusted HR, 1.84 [1.09-3.11]), AVA/weight <0.01 cm/kg (adjusted HR, 1.78 [1.07-2.98]), and AVA/body mass index <0.029 cm/kg per meter square (adjusted HR, 1.75 [1.04-2.93]). AVA/height showed better predictive performance than AVA/BSA with improved reclassification and better discrimination (net reclassification improvement: 0.33 versus 0.28; integrated discrimination improvement: 0.10 versus 0.08; C statistic: 0.67 versus 0.65), whereas AVA/weight and AVA/body mass index showed lower predictive capacity. CONCLUSIONS: Among AVA normalization methods, AVA/height <0.45 cm/m followed by AVA/BSA <0.40 cm/m seem as robust parameters for defining high risk in asymptomatic aortic stenosis. The prognostic value of AVA/height deserves future research.
背景：目前的指南将主动脉瓣面积与体表面积标准化（AVA/BSA）<0.6 cm/m²的患者定义为重度主动脉瓣狭窄；然而，这一切断值从未得到验证。此外，尚不清楚将AVA标准化至其他身体大小指标是否能改善结局预测。我们旨在测试将AVA标准化至身体大小对于无症状主动脉瓣狭窄结局预测的价值。 方法与结果：我们纳入了289例诊断时无症状、射血分数保留且AVA<1.3 cm²的主动脉瓣狭窄患者。结局指标为主动脉瓣置换术的发生或全因死亡或随访期间的情况。AVA被标准化至BSA、身高、体重和体重指数。对于每个标准化指标，处于最低三分位数的患者发生事件的风险较高，而其他三分位数的结局相似。当AVA/BSA<0.4 cm/m²（调整后风险比[HR]，3.42[2.09 - 5.60]）、AVA/身高<0.45 cm/m（调整后HR，3.99[2.42 - 6.60]）、AVA/体重<0.01 cm/kg（调整后HR，3.37[2.07 - 5.49]）以及AVA/体重指数<0.029 cm/kg/m²（调整后HR，3.23[1.99 - 5.24]）时，发生事件的风险较高。当AVA/身高<0.45 cm/m（调整后HR，2.18[1.28 - 3.71]）时，死亡风险较高，其次是AVA/BSA<0.40 cm/m²（调整后HR，1.84[1.09 - 3.11]）、AVA/体重<0.01 cm/kg（调整后HR，1.78[1.07 - 2.98]）以及AVA/体重指数<0.029 cm/kg/m²（调整后HR，1.75[1.04 - 2.93]）。AVA/身高显示出比AVA/BSA更好的预测性能，重新分类改善且鉴别力更好（净重新分类改善：0.33对0.28；综合鉴别改善：0.10对0.08；C统计量：0.67对0.65），而AVA/体重和AVA/体重指数显示出较低的预测能力。 结论：在AVA标准化方法中，AVA/身高<0.45 cm/m，其次是AVA/BSA<0.40 cm/m²似乎是定义无症状主动脉瓣狭窄高风险的可靠参数。AVA/身高的预后价值值得未来研究。
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