Department of Cardiovascular Sciences, University of Leicester and Cardiovascular Theme, NIHR Leicester Biomedical Research Centre, Glenfield Hospital, United Kingdom (D.C.S.C., A.S., L.L.N., G.P.M.).
Multidisciplinary Cardiovascular Research Centre, The Division of Biomedical Imaging, Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds University, United Kingdom (J.P.G.).
Circ Cardiovasc Imaging. 2020 Dec;13(12):e011763. doi: 10.1161/CIRCIMAGING.120.011763. Epub 2020 Dec 8.
The 2017 European Society of Cardiology guidelines for valvular heart disease included changes in the definition of severe aortic stenosis (AS). We wanted to evaluate its influence on management decisions in asymptomatic patients with moderate-severe AS.
We reclassified the AS severity of the participants of the PRIMID-AS study (Prognostic Importance of Microvascular Dysfunction in Asymptomatic Patients With AS), using the 2017 guidelines, determined their risk of reaching a clinical end point (valve replacement for symptoms, hospitalization, or cardiovascular death) and evaluated the prognostic value of aortic valve calcium score and biomarkers. Patients underwent echocardiography, cardiac magnetic resonance imaging, exercise tolerance testing, and biomarker assessment.
Of the 174 participants, 45% (56/124) classified as severe AS were reclassified as moderate AS. This reclassified group was similar to the original moderate group in clinical characteristics, gradients, calcium scores, and remodeling parameters. There were 47 primary end points (41 valve replacement, 1 death, and 5 hospitalizations-1 chest pain, 2 dyspnea, 1 heart failure, and 1 syncope) over 368±156 days follow-up. The severe and reclassified groups had a higher risk compared with moderate group (adjusted hazard ratio 4.95 [2.02-12.13] and 2.78 [1.07-7.22], respectively), with the reclassified group demonstrating an intermediate risk. A mean pressure gradient ≥31 mm Hg had a 7× higher risk of the primary end point in the reclassified group. Aortic valve calcium score was more prognostic in females and low valve area but not after adjusting for gradients. NT-proBNP (N-terminal pro-brain-type natriuretic peptide) and myocardial perfusion reserve were associated with the primary end point but not after adjusting for positive exercise tolerance testing. Troponin was associated with cardiovascular death or unplanned hospitalizations.
Reclassification of asymptomatic severe AS into moderate AS was common using the European Society of Cardiology 2017 guidelines. This group had an intermediate risk of reaching the primary end point. Exercise testing, multimodality imaging, and lower mean pressure gradient threshold of 31 mm Hg may improve risk stratification. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01658345.
2017 年欧洲心脏病学会瓣膜性心脏病指南对严重主动脉瓣狭窄（AS）的定义进行了修改。我们希望评估其对无症状中重度 AS 患者管理决策的影响。
我们使用 2017 年指南重新分类了 PRIMID-AS 研究（无症状 AS 患者微血管功能障碍的预后重要性）参与者的 AS 严重程度，确定了他们达到临床终点（因症状、住院或心血管死亡而更换瓣膜）的风险，并评估了主动脉瓣钙评分和生物标志物的预后价值。患者接受了超声心动图、心脏磁共振成像、运动耐量测试和生物标志物评估。
在 174 名参与者中，45%（56/124）被归类为严重 AS 的患者被重新归类为中度 AS。该重新分类组与原始中度组在临床特征、梯度、钙评分和重塑参数方面相似。在 368±156 天的随访中，共有 47 个主要终点（41 个瓣膜置换，1 例死亡，5 例住院治疗-1 例胸痛，2 例呼吸困难，1 例心力衰竭，1 例晕厥）。严重组和重新分类组的风险高于中度组（调整后的危险比分别为 4.95[2.02-12.13]和 2.78[1.07-7.22]），重新分类组显示出中间风险。平均压力梯度≥31mmHg 的患者，重新分类组发生主要终点的风险增加 7 倍。主动脉瓣钙评分在女性和低瓣面积中更具预后意义，但在调整梯度后则不然。N 端脑利钠肽前体（N-terminal pro-brain-type natriuretic peptide，NT-proBNP）和心肌灌注储备与主要终点相关，但在调整阳性运动耐量测试后则不然。肌钙蛋白与心血管死亡或计划外住院有关。
使用 2017 年欧洲心脏病学会指南，对无症状严重 AS 重新分类为中度 AS 较为常见。该组达到主要终点的风险处于中间水平。运动试验、多模态成像和 31mmHg 以下的平均压力梯度阈值可能会改善风险分层。注册：网址：https://www.clinicaltrials.gov。唯一标识符：NCT01658345。
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