Ambalavanan Jayachidambaram, Hubbard Carlos, Khan Leila Zeinab
Endocrinology and Metabolism, Cleveland Clinic, Cleveland, Ohio.
Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio.
AACE Clin Case Rep. 2024 Apr 26;10(4):152-155. doi: 10.1016/j.aace.2024.04.006. eCollection 2024 Jul-Aug.
BACKGROUND/OBJECTIVE: Teriparatide, an osteoanabolic agent similar to parathyroid hormone in properties, is used to manage severe osteoporosis. Aortic valve stenosis is a common valve condition observed in the elderly. Its natural history includes gradual progression toward severity. We present a case of a patient who had rapidly progressive aortic stenosis after teriparatide initiation.
An 84-year-old woman who was diagnosed with osteoporosis was treated with oral bisphosphonates. When she had spinal compression fractures, she was found to have primary hyperparathyroidism. She underwent parathyroidectomy and was treated with denosumab infusions every 6 months. However, after she experienced bilateral atypical femoral fractures, she was switched to teriparatide daily injections. Her laboratory test results showed a calcium level of 10 mg/dL (reference range, 8.5-10.2 mg/dL), 25-hydroxyvitamin D level of 38.2 ng/mL (reference range, 31.0-80.0 ng/mL), and phosphorus level of 3.3 mg/dL (reference, range, 2.7-4.8 mg/dL). On reviewing echocardiograms before and after teriparatide initiation, we found a rapid progression of her aortic stenosis from moderate to severe based on the mean gradients (23 to 40 mm Hg) and peak velocities (3.09 to 4 m/s), over a span of 10 months. She eventually required valve replacement.
Natural progression of mild to severe aortic stenosis typically occurs at the rate of 3 to 7 mm Hg per year over several years. Chronic exposure of human valvular endothelial cells to parathyroid hormone can trigger endothelial dysfunction and valvular calcification.
In patients with preexisting aortic stenosis, coordination of care with cardiology and echocardiographic monitoring while on therapy may be considered.
背景/目的：特立帕肽是一种性质与甲状旁腺激素相似的骨合成代谢药物，用于治疗严重骨质疏松症。主动脉瓣狭窄是老年人常见的瓣膜疾病。其自然病程包括逐渐加重。我们报告一例患者，在开始使用特立帕肽后出现快速进展的主动脉瓣狭窄。
一名84岁女性被诊断为骨质疏松症，接受口服双膦酸盐治疗。当她发生脊柱压缩性骨折时，发现患有原发性甲状旁腺功能亢进症。她接受了甲状旁腺切除术，并每6个月接受一次地诺单抗输注治疗。然而，在她发生双侧非典型股骨骨折后，改为每日注射特立帕肽。她的实验室检查结果显示血钙水平为10mg/dL（参考范围8.5 - 10.2mg/dL），25 - 羟维生素D水平为38.2ng/mL（参考范围31.0 - 80.0ng/mL），血磷水平为3.3mg/dL（参考范围2.7 - 4.8mg/dL）。在回顾开始使用特立帕肽前后的超声心动图时，我们发现基于平均压差（从23至40mmHg）和峰值流速（从3.09至4m/s），她的主动脉瓣狭窄在10个月内从中度迅速进展为重度。她最终需要进行瓣膜置换。
轻度至重度主动脉瓣狭窄的自然进展通常在数年中以每年3至7mmHg的速度发生。人瓣膜内皮细胞长期暴露于甲状旁腺激素可引发内皮功能障碍和瓣膜钙化。
对于已有主动脉瓣狭窄的患者，在治疗期间可考虑与心脏病学进行护理协调并进行超声心动图监测。
