主动脉瓣狭窄患者中心肌纤维化与死亡率的性别特异性关联

Sex-Specific Association of Myocardial Fibrosis With Mortality in Patients With Aortic Stenosis.

作者信息

Kwak Soongu, Singh Anvesha, Everett Russell J, Treibel Thomas A, Lim Jaehyun, Won Sungho, Williams Michelle C, Loganathan Krithika, Bing Rong, Craig Neil, Singh Trisha, Joshi Shruti, Lee Heesun, Lee Whal, Kim Yong-Jin, Chin Calvin W L, Fukui Miho, Al Musa Tarique, Rigolli Marzia, Tastet Lionel, Dobson Laura E, Wiesemann Stephanie, Ferreira Vanessa M, Captur Gabriella, Lee Sahmin, Schulz-Menger Jeanette, Schelbert Erik B, Clavel Marie-Annick, Park Sung-Ji, Pellegrini Costanza, Hadamitzky Martin, Gerber Bernhard L, Newby David E, Myerson Saul G, Pibarot Phillipe, Cavalcante João L, McCann Gerry P, Greenwood John P, Moon James C, Dweck Marc R, Lee Seung-Pyo

机构信息

Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea.

Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, United Kingdom.

出版信息

JAMA Cardiol. 2025 May 1;10(5):446-455. doi: 10.1001/jamacardio.2024.5593.

DOI:10.1001/jamacardio.2024.5593

PMID:39969863

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC11840686/

Abstract

IMPORTANCE

Myocardial fibrosis in aortic stenosis (AS) may exhibit sex differences. However, its prognostic significance in women with AS remains unclear.

OBJECTIVE

To investigate sex differences in myocardial fibrosis assessed by cardiovascular magnetic resonance (CMR) and evaluate its prognostic value in women and men with AS.

DESIGN, SETTING, AND PARTICIPANTS: Patients with severe AS who underwent CMR before aortic valve replacement (AVR) were prospectively enrolled from 13 international sites between March 2011 and September 2021. Myocardial fibrosis was evaluated using extracellular volume fraction (ECV%) and late gadolinium enhancement (LGE). The main analysis was conducted on patients without obstructive coronary artery disease (CAD), defined as those with no history of myocardial infarction and no concomitant coronary artery bypass grafting. Data were analyzed from December 2023 to February 2024.

EXPOSURES

Surgical or transcatheter AVR.

MAIN OUTCOMES AND MEASURES

The primary outcome was post-AVR all-cause mortality and the secondary outcome was cardiovascular mortality.

RESULTS

Of 822 patients, 670 were without obstructive CAD (368 men [55%] and 302 women [45%]). Among these, women and men had a similar age (median, 72 years vs 71 years, respectively), comorbidities, and AS severity. ECV% was similar between sexes; however, women had less LGE (both infarct and noninfarct LGE). After a median follow-up of 3.7 (IQR, 2.1-4.7) years, there were 76 deaths (11.3%), including 29 adjudicated cardiovascular deaths, in patients without obstructive CAD. Increasing ECV% and LGE were associated with higher all-cause and cardiovascular mortality in both sexes. Cox analyses demonstrated that both ECV% and LGE were associated with higher all-cause mortality without significant interaction by sex (women: adjusted hazard ratio [HR], 1.08 per 1% ECV% increase; 95% CI, 1.04-1.12; P < .001; men: adjusted HR, 1.01; 95% CI, 0.96-1.06; P = .66; P for interaction by sex = .09 and women: adjusted HR, 2.49 for the presence of LGE; 95% CI, 1.07-5.80; P = .03; men: adjusted HR, 1.82; 95% CI, 1.00-3.32; P = .04; P for interaction by sex = .68). In the entire population (n = 822), both noninfarct and infarct-related LGE were associated with increased mortality without significant interaction by sex.

CONCLUSIONS AND RELEVANCE

In this study, patients with severe AS who underwent AVR exhibited similar ECV% between sexes, while women had lower LGE. Increased myocardial fibrosis provided important prognostic value for both sexes.

摘要

重要性

主动脉瓣狭窄（AS）中的心肌纤维化可能存在性别差异。然而，其在AS女性患者中的预后意义仍不明确。

目的

研究通过心血管磁共振（CMR）评估的心肌纤维化的性别差异，并评估其在AS男性和女性患者中的预后价值。

设计、设置和参与者：2011年3月至2021年9月期间，从13个国际地点前瞻性纳入了在主动脉瓣置换术（AVR）前接受CMR检查的重度AS患者。使用细胞外容积分数（ECV%）和延迟钆增强（LGE）评估心肌纤维化。主要分析针对无阻塞性冠状动脉疾病（CAD）的患者进行，定义为无心肌梗死病史且未同时进行冠状动脉旁路移植术的患者。2023年12月至2024年2月对数据进行分析。

暴露因素

外科或经导管AVR。

主要结局和测量指标

主要结局是AVR后的全因死亡率，次要结局是心血管死亡率。

结果

在822例患者中，670例无阻塞性CAD（368例男性[55%]和302例女性[45%]）。其中，女性和男性年龄相似（中位数分别为72岁和71岁），合并症和AS严重程度也相似。两性之间的ECV%相似；然而，女性的LGE（梗死和非梗死LGE）较少。在无阻塞性CAD的患者中，中位随访3.7（四分位间距，2.1 - 4.7）年后，有76例死亡（11.3%），包括29例经判定的心血管死亡。ECV%和LGE升高与两性的全因和心血管死亡率升高相关。Cox分析表明，ECV%和LGE均与较高的全因死亡率相关，且无显著的性别交互作用（女性：每增加1% ECV%，调整后的风险比[HR]为1.08；95%置信区间，1.04 - 1.12；P <.001；男性：调整后的HR为1.01；95%置信区间，0.96 - 1.06；P =.66；性别交互作用的P值 =.09；女性：存在LGE时调整后的HR为2.49；95%置信区间，1.07 - 5.80；P =.03；男性：调整后的HR为1.82；95%置信区间，1.00 - 3.32；P =.04；性别交互作用的P值 =.68）。在整个队列（n = 822）中，非梗死和梗死相关的LGE均与死亡率增加相关，且无显著的性别交互作用。