Cardiac damage in aortic stenosis

Do you know the classification?

As we have been following recently in valvular heart disease, there are many efforts to try to stratify patients early before irreversible damage to the heart occurs. In calcific aortic stenosis, current guidelines recommend that the intervention occur only in the presence of symptoms or in the drop in the ejection fraction. Less robust indications deal with asymptomatic patients, but with a peak speed greater than 5m/s and accelerated progression of stenosis, but they still need further studies.

In light of this, some researchers have presented a new classification of severity for aortic stenosis, based mainly on the hemodynamic repercussions resulting from valve obstruction and which has even presented a review, and therefore has been expanded.

Let us go to the classification proposal:

Stage 0 – Absence of concomitant cardiac injury.

Stage 1 – LV mass increase (men> 115mg/m2; Women> 95g/m2);

E e’> 14 (grade II diastolic dysfunction);

LVEF <60%;

LV Strain <15%.

Stage 2 – Vol AE> 34 mL/m2;

AF

Moderate MR

Stage 3 – PASP > 60 mmHg;

Moderate TR

Stage 4 – moderate RV systolic dysfunction;

Stroke Volume < 30mL/m2.

Only one item contemplated already established the patient as having a more advanced stage. Moreover, it was seen that the outcomes’ incidence was higher in those in more advanced stages, with the cut proposed by the author of the stage 2 score.

Even in a group of patients with asymptomatic aortic stenosis, the incidence of valve replacement or mortality over 3 years was high. Thus, decision-making for intervention in this group of patients is still a challenge and having a tool that better stratifies those who would benefit from an early approach would make an enormous contribution to long-term follow-up.

Faced with the proposal, the reader may be wondering:

Nevertheless, these changes take place in other pathologies too; can you use them in aortic stenosis?

In addition, here is perhaps the greatest criticism of the proposed stratification model. Patients, who present other pathologies concurrently, such as ischemic disease, may develop certain cardiac changes without being secondary to the hemodynamic repercussions of aortic stenosis.

We cannot deny that a score that is a predictor of outcomes in this population is very interesting, since a 45% increase in the risk of mortality was found for each stage of increase. However, knowing the limitations inherent to the method, understanding that many patients may be asymptomatic and already starting to develop irreversible cardiac damage makes us better understand the dynamics of the pathology and approach the ideal moment for intervention.

Soon after, the same group published the same classification, but now in symptomatic patients. The proposal was not to evaluate the indication of intervention, since it was already indicated, but to try to find a series of data that would raise the prediction for a more reserved prognosis. They found patients who were in stages 3 or 4 had a worse prognosis, that is, those with involvement of the right side of the heart with pulmonary hypertension or systolic dysfunction of the right ventricle.

Suggested literature:

1 – Tastet L, Tribouilloy C, Maréchaux S, et al. Staging Cardiac Damage in Patients With Asymptomatic Aortic Valve Stenosis. J Am Coll Cardiol. 2019 Jul 30;74(4):550-563.

2 – Vollema EM, Amanullah MR, Ng ACT, et al. Staging Cardiac Damage in Patients With Symptomatic Aortic Valve Stenosis. J Am Coll Cardiol. 2019 Jul 30;74(4):538-549.

 

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