Association of mitral anular calcium with new thromboembolic stroke and cardiac events at 39-month follow-up in elderly patients

Lethal hemopericardium caused by infection of mitral annular calcification: An autopsy case report

Mitral annular calcification (MAC) is a chronic and degenerative condition involving calcification of the mitral annulus. MAC is a risk factor for coronary artery disease, cardiovascular events, stroke, and cardiovascular death. However, patients with MAC are often asymptomatic. Herein, we present the first case of cardiac tamponade due to infection of MAC in forensic pathology. An 80-year-old woman was found in cardiopulmonary arrest shortly after experiencing fatigue. She was transferred to a hospital, and despite chest compression and ventilation, she was pronounced dead due to no response. Postmortem computed tomography, autopsy, and histological examination showed MAC, abscess formation involving Gram-positive cocci on the MAC, and fistulation of the abscess into the intracardial pericardial cavities, resulting in a massive lethal hemopericardium.

Mitral Annular Calcification Related Infective Endocarditis: A Contemporary Systematic Review

Mitral annular calcification (MAC) is a chronic degenerative process often found incidentally on imaging. MAC is associated with elevated risk of atherosclerosis and stroke. The association between MAC and the risk of infective endocarditis (IE) is less well known. Therefore, we conducted this systematic review in order to understand the diagnosis, clinical outcomes, and management of IE associated with MAC. We conducted a systematic review of published data regarding MAC related IE in various databases until November 20, 2019. Case series and cohort studies were included. A total of 8 studies with a cohort of 113 patients were included. Mean age was 69 years with equal gender distribution (50% female). Hypertension (55.8%) was the most common comorbidity seen in this patient population. IE was diagnosed by either antemortem trans esophageal echocardiographic examination (76%) or post-mortem autopsy (24%). Staphylococcus aureus (47%) was the most common pathogen identified. MAC was adjudicated to be moderate-to-severe in 100% of identified cases, with 77.9% of cases presenting with distinct vegetation's. Twenty-six percent of patients (n = 29) underwent surgery. MAC may be associated with development of IE. Echocardiography is the most common non-invasive technique for diagnosis. Due to the difficulties associated with antemortem diagnosis, diagnosis is occasionally made on post-mortem examination. Neurologic complications are frequently encountered, and reported mortality is high in MAC associated IE.

Mitral annular calcification is associated with atrial fibrillation and major cardiac adverse events in atrial fibrillation patients: A systematic review and meta-analysis

BACKGROUND

The incidence of atrial fibrillation (AF) varies from 5.4% to 47.1% in patients with mitral annulus calcification (MAC). We conducted a systematic review and meta-analysis on the association between MAC and AF, as well as the relation between MAC and major cardiac adverse events (MACEs) in AF patients.

METHODS

We conducted comprehensive search for literature on associations between MAC and AF using the following databases: MEDLINE, PubMed, Embase, and the Web of Science. The pooled odds ratio (OR) or relative risk and the corresponding 95% confidence intervals (CIs) were calculated to assess the relationship between MAC and AF, as well as the rates of MACEs in AF patients with or without MAC.

RESULTS

Thirteen studies met our eligibility criteria on associations between MAC and AF, including 6232 patients with MAC and 15,199 patients without MAC. Moreover, 5 studies met our eligibility criteria on the rates of MACEs in AF patients with or without MAC. The pooled analysis demonstrated a statistically significant increased risk of development of incident AF in patients with MAC than those without MAC (random effects OR: 2.34; 95% CI: 1.91, 2.85; P = .000). And the pooled analysis demonstrated a statistically significant increased risk of development of MACEs in AF patients with MAC (random effects OR: 2.34; 95% CI: 1.24, 4.41; P = .009).

CONCLUSION

MAC was independently associated with AF and AF patients with MAC were at greater risk for cardiovascular and cerebrovascular events.

Exuberant mitral annular calcification

Mitral annular calcification (MAC) is a chronic, progressive process characterized by calcium deposition on the mitral valve annulus. There is no current grading system to relay the severity of MAC. The primary purpose of this study was to investigate the extreme end of the severity spectrum in order to describe "exuberant mitral annular calcification", and a retrospective chart review of all patients with exuberant mitral annulus calcification evaluated at Mayo Clinic Rochester between January 1996 and December 2014 was performed. This is the first study to define criteria of "exuberant mitral annular calcification", emphasizing the importance of identifying the extreme degree of mitral annular calcification.

Assessment of left atrial volume and mechanical functions using real-time three-dimensional echocardiography in patients with mitral annular calcification

Objective:

Mitral annular calcification (MAC) is degeneration of the fibrous annular ring of the mitral valve. Left atrial (LA) function and volume have been evaluated by many methods; however, none have used real-time three-dimensional echocardiography (RT3DE) in patients with MAC. Our study is the first to evaluate LA volume and mechanical function using RT3DE in patients with MAC.

Methods:

Our study was a prospective cross-sectional study. In total, 32 patients with echocardiographic evidence of MAC and 30 volunteers without MAC were enrolled in the study. Kolmogorov–Smirnov test, Student’s t-test, Mann-Whitney U test, chi-square test, Pearson’s correlation test, and multiple linear regression analyses were used in this study.

Results:

LA diameter was significantly higher in patients with MAC (38.5±3.8 vs. 31.1±2.9, p<0.001). Maximum LA volume (49.6±11.2 vs. 35.6±2.5, p<0.001), minimum LA volume (23.8±7.9 vs. 12.6±2.3, p<0.001), and LA volume index (LAVI) (26.9±6.1 vs. 20.5±2.4, p<0.001) were also higher in the MAC group. LAVI was correlated with age (p<0.001), blood urea nitrogen levels (p=0.089), total cholesterol levels (p=0.055), left ventricular systolic myocardial velocity (p=0.048), E/A ratio (p<0.001), and MAC (p<0.001). Multiple linear regression analyses revealed that age (β=0.390, p<0.001) and MAC (β=0.527, p<0.001) were independent predictors of LAVI.

Conclusion:

We found that LA mechanical function was impaired in patients with MAC. Furthermore, age and MAC were independent predictors of increased LAVI according to our RT3DE examination.

A large cardiac mass: diagnosis of caseous mitral annular calcification and determining optimum management strategy

A 64-year-old woman with dizziness and blurry vision underwent an evaluation for a possible stroke with a head-neck CT scan and a transthoracic echocardiogram. The head-neck CT scan was unremarkable, but the echocardiogram was notable for a 2.0 × 2.3 cm heterogeneous echodensity attached to the mitral valve. After a transesophageal echocardiogram and chest CT scan, the mass was determined to be a caseous mitral annular calcification, CMAC. This entity is a rare variant of MAC with an estimated prevalence of 0.068%. Echocardiographic techniques can distinguish CMAC from other intracardiac masses such as tumor, cyst, or abscess. CMAC is associated with cerebrovascular accidents; however, optimal treatment is controversial given the rarity of this clinical finding. Management strategies should be tailored based on the patient's presentation, risk factors, and overall clinical circumstances.

Interactions between cardiovascular and cerebrovascular disease

OPININION STATEMENT: All patients with ischemic stroke should undergo a comprehensive assessment of cardiovascular risk. Patients with carotid artery disease, symptoms of cerebral ischemia and high cardiovascular risk profiles should be considered for noninvasive testing for coronary artery disease (CAD). Routine testing for CAD before carotid endarterctomy is not recommended. Patients with coexisting coronary and carotid artery disease should be more aggressively treated for reducing their "very high" risk of cardiovascular events. In patients candidates to carotid revascularization, a preoperative coronary angiography and coronary revascularization are not recommended. Warfarin is recommended in all patients with moderate to high risk of stroke. Novel oral anticoagulants represent an attractive alternative to warfarin. However, their place in therapy in clinical practice is not yet established. Percutaneous closure of the left atrial appendage for stroke prophylaxis may be considered in selected patients with atrial fibrillation and contraindications for oral anticoagulant therapy. Warfarin is not indicated in patients with heart failure who are in sinus rhythm. Percutaneous closure of patent foramen does not seem to be superior to medical therapy for the prevention of recurrences in patients with cryptogenic stroke.

Patients with echocardiographic aortic valve calcium or mitral annular calcium have an increased prevalence of moderate or severe coronary artery calcium diagnosed by cardiac computed tomography

The association between aortic valve calcium (AVC) and mitral annular calcium (MAC), as diagnosed by two-dimensional echocardiography, was investigated in 138 patients (76 women and 62 men, mean age 64±8 years) seen in a private cardiology practice at the New York Medical College. Coronary artery calcium (CAC) scores were diagnosed by 64-multislice computed tomography. AVC was present in 25 of 57 patients (44%) with moderate or severe CAC (a CAC score of more than 100) and in 15 of 81 patients (19%) with no or mild CAC (a CAC score of 0 to 100), P<0.001. Moderate or severe AVC was present in nine of 57 patients (16%) with moderate or severe CAC, and in two of 81 patients (2%) with no or mild CAC, P<0.005. MAC was present in 18 of 57 patients (32%) with moderate or severe CAC, and in seven of 81 patients (9%) with no or mild CAC, P<0.001. Moderate or severe MAC was present in eight of 57 patients (14%) with moderate or severe CAC, and in two of 81 patients (2%) with no or mild CAC, P<0.001.

Association of mitral annulus calcification with high-sensitivity C-reactive protein, which is a marker of inflammation

Objectives. There are limited clinical data revealing the relationship between mitral annular calcification (MAC) and systemic inflammation. The goal of the present study was to compare high-sensitivity C-reactive protein (hs-CRP) levels in patients with and without MAC and investigate the relationship between MAC and hs-CRP. Methods. One hundred patients with MAC who underwent transthoracic echocardiography (TTE) and 100 age-matched controls without MAC who underwent TTE were included in our study. Hs-CRP levels were compared between groups. Results. Prevalence of female gender, hypertension, and coronary artery disease were significantly higher in the MAC group than in the control group (64% versus 45%, P = 0.007, 42% versus 28%, P = 0.03 and 37% versus 18%, P = 0.003, resp.). On multivariate analysis, age, gender, and coronary artery disease were the only independent predictors of MAC. The levels of hs-CRP were higher in the MAC group than in the control group (2.02 ± 0.35 versus 1.43 ± 0.47 mg/dl, P < 0.001). This increase in hs-CRP levels in the MAC group persisted in patients without hypertension, coronary artery disease, and in male patients when compared to the control group. Conclusions. Our study demonstrated that hs-CRP, which is a sensitive marker of systemic inflammation, increased in patients with MAC.

Infective endocarditis on mitral annular calcification: a case report

Introduction

Mitral annular calcification is a common finding in elderly patients; it is considered a benign cardiac abnormality but it can be a predisposing factor for infective endocarditis. Although described in numerous necropsy studies, endocarditis on mitral annular calcification has rarely been reported during life, and the frequency of sepsis can be underestimated because of difficult diagnosis.

Case presentation

We present a case of infective endocarditis on mitral annulus calcification in a patient with acute coronary syndrome, diagnosed with transthoracic echocardiography.

Conclusion

Transthoracic echocardiography may contribute to a correct diagnosis, showing typical findings of infective endocarditis on mitral annular calcification in order to administrate an adequate antibiotic prophylaxis in patients undergoing endoscopic or invasive procedures.

Predicting clinically unrecognized coronary artery disease: use of two- dimensional echocardiography

BACKGROUND

2-D Echo is often performed in patients without history of coronary artery disease (CAD). We sought to determine echo features predictive of CAD.

METHODS

2-D Echo of 328 patients without known CAD performed within one year prior to stress myocardial SPECT and angiography were reviewed. Echo features examined were left ventricular and atrial enlargement, LV hypertrophy, wall motion abnormality (WMA), LV ejection fraction (EF) < 50%, mitral annular calcification (MAC) and aortic sclerosis/stenosis (AS). High risk myocardial perfusion abnormality (MPA) was defined as >15% LV perfusion defect or multivessel distribution. Severe coronary artery stenosis (CAS) was defined as left main, 3 VD or 2VD involving proximal LAD.

RESULTS

The mean age was 62 +/- 13 years, 59% men, 29% diabetic (DM) and 148 (45%) had > 2 risk factors. Pharmacologic stress was performed in 109 patients (33%). MPA was present in 200 pts (60%) of which, 137 were high risk. CAS was present in 166 pts (51%), 75 were severe. Of 87 patients with WMA, 83% had MPA and 78% had CAS. Multivariate analysis identified age >65, male, inability to exercise, DM, WMA, MAC and AS as independent predictors of MPA and CAS. Independent predictors of high risk MPA and severe CAS were age, DM, inability to exercise and WMA. 2-D echo findings offered incremental value over clinical information in predicting CAD by angiography. (Chi square: 360 vs. 320 p = 0.02).

CONCLUSION

2-D Echo was valuable in predicting presence of physiological and anatomical CAD in addition to clinical information.

Mitral annular calcification as a marker of complex aortic atheroma in patients with stroke of uncertain etiology

The aim of this study was to evaluate the presence of dense mitral annular calcification as a marker of complex aortic atherosclerosis in patients with stroke of uncertain etiology. One hundred twenty-one patients with stroke of uncertain etiology were evaluated for complex aortic atherosclerotic plaques; their presence and severity were correlated with transthoracic echocardiographic findings, demographic data, and cardiovascular risk factors. Complex plaques in the ascending aorta or aortic arch were found in 72 of the 121 patients (59.5%). The only difference seen in patients with or without plaques was the presence of dense mitral annular calcification (58.3 vs 16.3%; P < 0.001). Dense mitral annular calcification (n = 50) was associated with higher prevalence of complex aortic plaques (84.0% vs 42.3%; P < 0.001), mobile components (28.0% vs 9.9%; P < 0.01), and protruding (80.0% vs 36.6%; P < 0.001), ulcerated (16.0% vs 1.4%; P < 0.01), and multisite complex plaques (46.0% vs 9.0%; P < 0.001). Therefore, in patients with stroke of uncertain etiology dense mitral annular calcification is an important marker of aortic atherosclerosis with high risk of embolism, and this association may explain in part the high prevalence of stroke and peripheral embolism in patients with mitral annular calcification.

Comparison of prevalence of >70% diameter narrowing of one or more major coronary arteries in patients with versus without mitral annular calcium and clinically suspected coronary artery disease

The prevalence of >70% narrowing of 1, 2, or 3 major coronary arteries and of 3 major coronary arteries was investigated in 2,465 patients (1,437 men, 1,028 women; mean age 69 +/- 13 years) with severe, moderate, mild, or no mitral annular calcium (MAC) diagnosed by 2-dimensional echocardiography who underwent coronary angiography for suspected coronary artery disease. Greater than 70% narrowing of 1, 2, or 3 major coronary arteries was present in 259 of 315 patients (82%) with severe MAC (group 1), in 835 of 1,052 patients (79%) with moderate or mild MAC (group 2), and in 756 of 1,098 patients (69%) with no MAC (group 3) (p <0.001 comparing group 1 with group 3 and group 2 with group 3). Greater than 70% narrowing of 3 major coronary arteries was present in 149 of 315 patients (47%) in group 1, in 366 of 1,052 patients (35%) in group 2, and in 325 of 1,098 patients (30%) in group 3 (p <0.001 comparing group 1 with group 3 and group 1 with group 2; p <0.01 comparing group 2 with group 3). In conclusion, MAC is associated with obstructive >or=1-vessel coronary artery disease and with obstructive 3-vessel coronary artery disease.

Heart disease and aging

CAD is the most common cause of death in older persons and was present in 43% of 1,160 men and in 41% of 2,464 women, mean age 81 years. Hypertension was present in 60% of these older women and in 57% of these older men. The prevalence of valvular aortic stenosis, aortic regurgitation, mitral regurgitation, and MAC increases with age in older men and in older women. The prevalence and incidence of CHF increase with age. CHF is the most common cause of hospitalization in persons aged 65 years and older. The prevalence of normal LV ejection fraction associated with CHF increases with age and is higher in older women than in older men. The prevalence of chronic atrial fibrillation increases with age and was present in 16% of 1,160 older men and in 13% of 2,464 older women. Atrial fibrillation is an independent predictor of new coronary events and thromboembolic stroke in older persons. Older persons who have unexplained syncope should have 24-hour ambulatory electrocardiograms to determine whether pauses of longer than 3 seconds are present that require permanent pacemaker implantation.

Infective Endocarditis and Pseudoaneurysm: Fatal Complications of Mitral Annular Calcification

We present a case of successful surgical repair for infected mitral valve and left ventricular pseudoaneurysm, which can be fatal complications of mitral annular calcification.

Increased prevalence of coronary artery disease, silent myocardial ischemia, complex ventricular arrhythmias, atrial fibrillation, left ventricular hypertrophy, mitral annular calcium, and aortic valve calcium in patients with chronic renal insufficiency

Cardiovascular morbidity and mortality is high in patients with chronic renal insufficiency. Patients with chronic renal insufficiency have an increased prevalence of coronary artery disease, silent myocardial ischemia, complex ventricular arrhythmias, atrial fibrillation, left ventricular hypertrophy, mitral annular calcium, and aortic valve calcium than patients with normal renal function. These risk factors for cardiovascular morbidity and mortality contribute to the increased incidence of cardiovascular morbidity and mortality seen in patients with chronic renal insufficiency.

Clinical significance of calcification of the fibrous skeleton of the heart and aortosclerosis in community dwelling elderly. The Cardiovascular Health Study (CHS)

BACKGROUND

Mitral annular calcification (MAC), aortic annular calcification (AAC), and aortic valve sclerosis (AVS) are associated with aging, and MAC and AVS are markers of advanced atherosclerosis. No studies have examined the prevalence and the clinical relevance of all 3 forms of calcification in a single free-living elderly population.

METHODS

We used 2-dimensional echocardiography to evaluate MAC, AAC, AVS and all 3 combined in 3929 participants, mean age 76 +/- 5 years, 60% women, in the Cardiovascular Health Study, a prospective community-based observational study designed to assess cardiovascular disease (CVD) risk factors and outcomes in elderly persons.

RESULTS

Mitral annular calcification was found in 1640 (42 %) subjects, AAC in 1710 (44 %), AVS in 2114 (54 %), and all 3 combined in 662 (17 %). The participants with these findings were older than those without them, and those with MAC had worse cardiovascular, renal, metabolic, and functional profile than those with AAC and AVS. Age-, sex-, and race-adjusted logistic regression analysis found a significant association between the 3 calcification categories and CVD, the strongest being between the combined group with congestive heart failure (odds ratio 2.04, 95% CI 1.34-3.09). In highly adjusted models, only MAC was associated with CVD, and the strength of association was related to the severity of MAC.

CONCLUSIONS

In free-living elderly, MAC, AAC, and AVS are highly prevalent and are associated with CVD. Mitral annular calcification in particular has strong association with CVD, and with an adverse biomedical profile.

Prevalence of valve calcium and association of valve calcium with coronary artery disease, atherosclerotic vascular disease, and all-cause mortality in 137 patients undergoing hemodialysis for chronic renal failure

Of 137 patients (mean age 63 years) who underwent hemodialysis for chronic renal failure, 65 (47%) had mitral valve calcium, mitral annular calcium, or aortic valve calcium. Thirty-eight of 65 patients (59%) who had valve calcium died at 3.5-year follow-up versus 21 of 72 patients (29%) who did not have valve calcium and who died at 4.3-year follow-up (p = 0.0005).

Is Carotid Atherosclerosis More Important in Patients With Mitral Annular Calcification Than in Those Without?

It has been suggested that mitral annular calcification (MAC) may be a manifestation of generalized atherosclerosis. However, how the incidence and extent of coronary artery disease (CAD) are affected by the coexistence of carotid atherosclerosis (CAS) in patients with versus without MAC have not yet been studied. We studied 101 patients with echocardiographic MAC and 52 controls without MAC to investigate the clinical impact of CAS on the frequency and severity (defined as the number of obstructed vessels) of CAD in patients with MAC. Carotid Doppler ultrasonographic examination was performed on all patients before coronary angiography. In patients with both MAC and CAS, the incidences of CAD and multivessel disease (> or = 2 vessel or left main coronary artery disease) were significantly higher than in the control group with CAS alone (91% versus 68%, P = 0.008 and 76% versus 44%, P = 0.004, respectively). On the other hand, among study and control patients without CAS, although the frequencies of CAD and multivessel disease were higher in patients with MAC, interestingly, the differences were not statistically significant (37% versus 58% and 15% versus 26%, respectively, P > 0.05 for both). Stepwise multiple logistic regression analysis revealed that CAS (P < 0.001), MAC (P < 0.01) and, to a limited extent hypertension (P = 0.054), were independent predictors for the presence of CAD. In conclusion, the coexistence of CAS is more important in patients with MAC than in those without as it provides valuable information about the incidence and severity of underlying CAD. In cases with MAC but without CAS, MAC could be caused by factors other than atherosclerosis.

Common cardiovascular issues encountered in geriatric critical care

The incidence and prevalence of CV disease is high in the growing US elderly population. It is common for CV disease to be either the primary or secondary problem for elderly patients receiving critical care. The therapeutic options for CV problems experienced in the critical care setting range from medical management with the goal of symptom relief and comfort care to invasive therapies such as PCI, intraaortic balloon pump therapy, invasive monitoring, and cardiac surgery. Age alone is not a contraindication for any of the invasive therapies. Instead, a careful risk-benefit analysis should be performed for each individual patient, taking into consideration physiologic age, comorbid conditions, other disabilities, and an assessment of quality of life. Additionally, the goals (symptom relief, improvement of quality of life, survival benefit) of any therapy should be clearly established for individual patients. End-of-life issues, cardiovascular surgery, and the disabling of ICDs deserve special consideration in the elderly, as these are often challenging issues that will likely be more frequently encountered in critical care settings as science and technology advance.

Infective endocarditis in the elderly: diagnosis and management

Infective endocarditis is seen with increasing frequency in older patients. This increase is due to the general aging of the population, improved survival of patients with congenital and valvular heart disease, and the increasing use of catheters and other prosthetic devices with resulting higher incidence of nosocomial endocarditis. In older patients, infective endocarditis frequently develops in the absence of underlying structural heart disease; atheromatous deposits and mitral annular calcification are two important risk factors in this population. Infective organisms in older patients are frequently enterococci and other gastrointestinal tract bacteria. A marked febrile response is uncommon whereas central nervous system symptoms are more common in older patients. Transesophageal echocardiography can be performed safely and is a major diagnostic tool with sensitivity of more than 90% in detecting vegetations as small as 2-5 mm. Appropriately drawn blood cultures provide bacteriologic diagnosis in 80%-99% of patients. Prolonged antibiotic therapy may be required in many instances depending on the infective organism. Early surgical therapy is advisable for patients who develop heart failure as a result of severe acute aortic valvular regurgitation. Valve replacement surgery can be performed with acceptable mortality and morbidity even in very elderly patients.

Association of mitral annulus calcification, aortic valve sclerosis and aortic root calcification with abnormal myocardial perfusion single photon emission tomography in subjects age < or =65 years old

OBJECTIVES

We examined the hypothesis that mitral annulus calcification (MAC), aortic valve sclerosis (AVS) and aortic root calcification (ARC) are associated with coronary artery disease (CAD) in subjects age < or =65 years.

BACKGROUND

Mitral annulus calcification, AVS and ARC frequently coexist and are associated with coronary risk factors and CAD in the elderly.

METHODS

We studied 338 subjects age < or =65 years who underwent evaluation of chest pain with myocardial perfusion single photon emission computed tomography (SPECT) and a two-dimensional transthoracic echocardiogram for other indications. The association of MAC, AVS and ARC with abnormal SPECT was evaluated by using chi-square analyses and logistic regression analyses.

RESULTS

Compared with no or one calcium deposit and no or one coronary risk factor other than diabetes, multiple (> or =2) calcium (or sclerosis) deposits with diabetes or multiple (> or =2) coronary risk factors were significantly associated with abnormal SPECT in women age < or =55 years old (odds ratio [OR], 20.00), in women age >55 years old (OR, 10.00) and in men age < or =55 years old (OR, 5.55). Multivariate analyses identified multiple calcium deposits as a significant predictor for an abnormal SPECT in women (p < 0.001), younger subjects age < or =55 years (p < 0.05) and the total group of subjects (p < 0.01).

CONCLUSIONS

When coronary risk factors are also taken into consideration, the presence of multiple calcium deposits in the mitral annulus, aortic valve or aortic root appears to be a marker of CAD in men < or =55 years old and women.

Mitral annulus calcification--a window to diffuse atherosclerosis of the vascular system

Mitral annulus calcification (MAC) is a chronic, non-inflammatory, degenerative process of the fibrous support structure of the mitral valve. It occurs more often in women and the elderly. MAC is associated with known atherosclerotic risk factors such as diabetes mellitus, hypertension and hypercholesterolemia. It is also known that patient with MAC have higher prevalence of left atrial and left ventricular enlargement, hypertrophic cardiomyopathy, atrial fibrillation, aortic valve calcification and stenosis, various cardiac conduction defects, bacterial endocarditis, cardiovascular events and stroke, though the etiological basis is unknown. Pathological studies from the 80s present a theory that MAC is a form of atherosclerosis. In order to test this theory we conducted during the last years a few clinical studies to examine the association of MAC and known atherosclerotic phenomena. We found higher prevalence of aortic atheroma in patients with MAC and atheroma thickness. We also found in MAC patients higher prevalence of carotid artery stenosis, coronary artery stenosis, peripheral artery stenosis and higher levels of beta2-Glycoprotein I antibodies in patients with MAC thickness equal or greater than 5 mm. These studies support the theory that MAC is a form of atherosclerosis and define a group of patients with higher prevalence of atherosclerotic disease in multiple blood vessels. The purpose of this review is to summarize the data concerning MAC and atherosclerotic processes, emphasizing that MAC in itself may be an atherosclerotic process.

Association between mitral annulus calcification and aortic atheroma: a prospective transesophageal echocardiographic study

BACKGROUND AND PURPOSE

Although mitral annulus calcification (MAC) has been reported to be a significant independent predictor of stroke, no causative relationship was proven. It is also known that aortic atheroma (AA), especially those >/=5 mm thick and/or protruding and/or mobile are associated with stroke. This study was designed to determine whether an association exists between MAC and AA.

METHODS

We prospectively evaluated the records of 279 consecutive patients who underwent transesophageal echocardiography (TEE) for various indications to measure the presence and characteristics of AA. The 105 patients in whom a diagnosis of MAC was made on transthoracic echocardiography (TTE) immediately preceding the TEE, were compared with 174 age-matched patients without MAC. MAC was defined as a dense, localized, highly reflective area at the base of the posterior mitral leaflet. We measured MAC thickness with two-dimensional-TTE in four-chamber view and AA thickness, protrusion and mobility with TEE. AA was defined as localized intimal thickening of >/=3 mm. A lesion was considered complex if there was plaque extending >/=5 mm into the aortic lumen and/or if it was protruding, mobile or ulcerated.

RESULTS

No differences were found between the groups in risk factors for atherosclerosis or in indications for referral for TEE. Significantly higher rates were found in the MAC group for prevalence of AA (91 vs. 44%, P<0.001), atheromas >/=5 mm thick (68 vs. 19%, P<0.001), protruding atheromas (44 vs. 15%, P<0.001), ulcerated atheromas (10 vs. 1%, P<0.001) and complex atheroma (74 vs. 22%, P<0.001). Sixty patients had MAC thickness >/=6 mm and 45<6 mm. AA thickness was significantly greater in the patients with a MAC thickness of >/=6 mm (6.1+/-2.8 vs. 5.0+/-2.6 mm, P=0.03). On multivariate analysis MAC, hypertension and age were the only independent predictors of AA (P=0.0001, 0.005 and 0.007, respectively).

CONCLUSIONS

There is a significant association between the presence and severity of MAC and AA. MAC may be an important marker for atherosclerosis of the aorta. This association may explain in part the high prevalence of systemic emboli and stroke in patients with MAC.

Association of mitral annular calcium and of aortic cuspal calcium with coronary artery disease in older patients

In a prospective study, mitral annular calcium (MAC) was present in 274 of 752 men (36%), mean age 80 years, and in 869 of 1,663 women (52%), mean age 82 years (p <0.0001); aortic cuspal calcium was present in 295 of 752 men (39%) and in 672 of 1,663 women (40%) without aortic cuspal calcium (p = NS). Coronary artery disease was present in 150 of 274 men (55%) with versus 192 of 478 men (40%) without MAC (p = 0.0001) and in 446 of 869 women (51%) with versus 276 of 794 women (35%) without MAC (p <0.0001); coronary artery disease was present in 167 of 295 men (57%) with versus 175 of 457 men (38%) without aortic cuspal calcium (p <0.0001), and in 360 of 672 women (54%) with versus 362 of 991 women (37%) without aortic cuspal calcium (p <0.0001).

The older man's heart and heart disease

CAD is the most common cause of death in older men and was present in 44% of 664 men, mean age 80 years. Independent risk factors for new coronary events in older men include increasing age, prior CAD, cigarette smoking, hypertension, diabetes mellitus, high serum total cholesterol, and low serum HDL cholesterol. In older men with hypertension, echocardiographic LVH is a powerful independent predictor of new coronary events, atherothrombotic brain infarction, and CHF. In 554 older men with a mean age of 80 years, two-dimensional and Doppler echocardiography demonstrated that the prevalence of aortic stenosis was 14%, 1 + aortic regurgitation or greater was 31%, rheumatic mitral stenosis was 0.4, 1 mitral regurgitation or greater was 32%, mitral annular calcium was 35%, hypertrophic cardiomyopathy was 3%, idiopathic dilated cardiomyopathy was 1%, left atrial enlargement was 29%, LVH was 41%, and abnormal LVEF was 29%. The prevalence and incidence of CHF increase with age in older persons. The prevalence of a normal LVEF associated with CHF as a result of prior myocardial infarction or hypertension was 22% in men aged 60 to 69 years, 33% in men aged 70 to 79 years, 41% in men aged 80 to 89 years, and 47% in men aged 90 years or older.

Valvular disease in the elderly

As the incidence of valvular disease in the elderly is increasing, understanding of its pathogenesis and natural progression as well as surgical approaches and device technologies are improving. Future studies are needed to develop medical interventions that slow or halt the degenerative valvular processes associated with aging. In addition, mechanical approaches with lower operative risks should be explored and the search should continue for a valve substitute that is durable, hemodynamically efficient, easy to implant, and does not require anticoagulation. Hopefully, future intervention trials will include quality of life assessments such as symptoms, functional capacity and perceptions of well being. At present, the degenerative valvular processes must be followed closely by the clinician, and individual management decisions for the elderly based on the type and severity of valve disease, comorbid medical conditions, and the risks and benefits of intervention, along with patient preferences, rather than on the chronologic age of the patient. It is becoming clear that both survival and quality of life outcomes can improve by consideration of surgery at the onset of indications, before further deterioration eliminates the opportunity to provide benefit for the elderly patient with valvular disease.

Risk factors for new thromboembolic stroke in patients > or = 62 years of age with chronic atrial fibrillation

In a prospective study of 312 older patients with chronic atrial fibrillation, at 36-month follow-up evaluation, new thromboembolic stroke developed in 162 of 312 patients (52%). Significant independent risk factors for new thromboembolic stroke were prior stroke (risk ratio = 1.6), rheumatic mitral stenosis (risk ratio = 2.0), left ventricular (LV) hypertrophy (risk ratio = 2.8), abnormal LV ejection fraction (risk ratio = 1.8), serum total cholesterol (risk ratio = 1.005), and serum high-density lipoprotein cholesterol (risk ratio = 0.96).

Cardiac changes in stroke patients and controls evaluated with transoesophageal echocardiography

In stroke patients several cardiac changes associated with embolism can be detected with transoesophageal echocardiography. Potential major cardiac embolic sources (e.g. atrial fibrillation, thrombi of left ventricle/atrium, vegetation, myxoma, dilated cardiomyopathy) have a causal relationship to embolism. Other changes with no certain causal relationship are regarded as potential minor cardiac embolic sources (e.g. atrial septal aneurysm, patent foramen ovale, mitral annular calcification, mitral valve prolapse, protruding atheroma of the aorta). We compared the prevalences of major and minor potential cardiac embolic sources in a stroke population with that in controls. One hundred and twenty-one patients with first-ever stroke were compared with 68 randomly selected controls. All subjects underwent magnetic resonance imaging of the brain, carotid ultrasound and transthoracic/transoesophageal echocardiography. The patients were slightly older (mean age 70.7 +/- 10.3 years) than the controls (65.5 +/- 15.5 years) (p < 0.05). Potential major cardiac embolic sources were found in 27% of the patients and in 4% of the controls (p < 0.001). The most common major potential embolic source was atrial fibrillation, detected in 22/121 patients. Fifteen of these also had spontaneous echocontrast in the left atrium. Eleven left atrial thrombi were found (four of these patients had atrial fibrillation and seven had sinus rhythm). A history of heart disease was more common in patients with a potential major cardiac embolic source or a carotid artery stenosis (77%) than in those patients without (44%) (p < 0.01). After excluding subjects with a major potential cardiac embolic source and/or carotid artery stenosis, no differences in the prevalence of minor potential cardiac embolic sources were found between patients (55%) and control subjects (47%) (p = NS). Even when subjects without a major potential cardiac embolic source or a carotid artery stenosis were categorized into three age groups (35-54, 55-74 and > 74 years) the prevalence of potential minor cardiac embolic sources did not differ between patients and controls. To conclude, major potential cardiac embolic sources are more common in an older population with first-ever stroke than in a comparable control group. However, potential minor cardiac embolic sources did not differ in prevalence in the patients compared with controls. Certain changes (e.g. atrial septal aneurysm) might have a potential embolic role in younger stroke patients but in our study no difference was found between older stroke patients and controls.

Association of mitral annular calcium with new thromboembolic stroke at 44-month follow-up of 2,148 persons, mean age 81 years

We investigated in a prospective study of 2,148 persons (mean age 81 years), the association between mitral annular calcium and new thromboembolic stroke at 44-month follow-up. Independent risk factors for new thromboembolic stroke were prior stroke (risk ratio 2.4), mitral annular calcium (risk ratio 2.6), atrial fibrillation (risk ratio 3.0), and male gender (risk ratio 1.6).

Cardiac valve calcification: characteristics of patients with calcification of the mitral annulus or aortic valve

AIMS

To determine whether mitral annular calcification and aortic valve calcification, with or without stenosis, are expressions of atherosclerotic disease.

METHODS

The incidence of atherosclerotic risk factors was analysed in patients with mitral annular calcification and aortic valve calcification and in control patients from a prospective echocardiographic database of 8160 consecutive patients; 657 patients (8%) were identified with mitral annular calcification and 815 (9%) with a calcified aortic valve, of whom 515 (6.3%) had stenosis with a minimal aortic valve gradient of 16 mm Hg. In these patients, cardiac and vascular risk factors were compared with 568 control patients using multiple logistic regression analysis.

RESULTS

Age (odds ratio (OR) varying from 5.78 to 104, depending on age class), female sex (OR 1.75), hypertension (OR 2.38), diabetes mellitus (OR 2.85), and hypercholesterolaemia (OR 2.95) were strongly and significantly associated with aortic valve calcification without stenosis, as were age (OR varying from 8.82 to 67, depending on age class), female sex (OR 2.22), hypertension (OR 2.72), diabetes mellitus (OR 2.49), and hypercholesterolaemia (OR 2.86) with mitral annular calcification. Age (OR varying from 1.11 to 7.7), hypertension (OR 1.91), and hypercholesterolaemia (OR 2.55) were strongly and significantly associated with stenotic aortic valve calcification.

CONCLUSIONS

Mitral annular calcification and stenotic or non-stenotic aortic valve calcification have a high incidence of atherosclerotic risk factors, suggesting they should be considered as manifestations of generalised atherosclerosis.

Role of transesophageal echocardiography in the management of thromboembolic stroke

Cardiac causes of stroke account for approximately 20% of strokes occurring in the United States. Transthoracic echocardiography (TTE) remains the cornerstone of non-invasive cardiac imaging, but transesophageal echocardiography (TEE) is superior for identifying potential cardiac sources of emboli, including left atrial thrombi, valvular vegetations, thoracic aortic plaque, patent foramen ovale, and spontaneous left atrial echocardiographic contrast. The diagnostic yield of TEE for potential cardiac causes of thromboembolism exceeds 50%. The impact of TEE on the clinical management of this group, however, remains undefined for most TEE-specific diagnoses. Thus, routine use of TEE in these patients has been questioned. The diagnostic yield is highest if the clinical history/physical examination suggests a cardiac source. However, the clinical scenario often dictates patient management, and TEE data are used to "validate" the clinical impression. Data from large, prospective, randomized (aspirin/warfarin) studies, in which TEE data are obtained from patients with suspected cardiac thromboembolism, are needed. If specific TEE diagnoses can be identified in which defined therapies are beneficial, "source of embolism" will continue to be the most common indication for TEE referral. In this paradigm, TEE (without initial TTE) will probably become a more direct diagnostic pathway. However, if these studies demonstrate that all patients with suspected cardiac source benefit from one (or no) therapy, independent of TEE data, referrals for TEE will decline. Results of ongoing randomized trials to evaluate the efficacy of TEE in patients with cryptogenic stroke or transient ischemic attack are awaited.

Prevalence of echocardiographic findings in 554 men and in 1,243 women aged > 60 years in a long-term health care facility

The prevalence of mitral regurgitation, valvular aortic stenosis, aortic regurgitation, hypertrophic cardiomyopathy, idiopathic dilated cardiomyopathy, and of left ventricular hypertrophy was not significantly different in older men and women. Older women had a significantly higher prevalence of rheumatic mitral stenosis, mitral annular calcium, and left atrial enlargement than older men, and older men had a significantly higher prevalence of abnormal left ventricular ejection fraction than older women.

Prevalence of atrial fibrillation and association of atrial fibrillation with prior and new thromboembolic stroke in older patients

OBJECTIVE

To correlate atrial fibrillation with the incidence of new thromboembolic (TE) stroke in older patients with and without prior TE stroke.

DESIGN

In a prospective study of 2101 older patients, electrocardiograms showed that atrial fibrillation was present in 283 patients (13%). At 42-month mean follow-up, atrial fibrillation was associated with the incidence of new TE stroke in patients with and without prior TE stroke.

SETTING

A large long-term health care facility where 2101 older patients were studied.

PATIENTS

The 2101 patients included 1451 women and 650 men, mean age 81 +/- 8 years (range 60 to 103).

MEASUREMENTS AND MAIN RESULTS

Atrial fibrillation was present in 283 of 2101 patients (13%). The mean age was 84 +/- 7 years in patients with atrial fibrillation and 81 +/- 8 years in patients with sinus rhythm (P = .0001). The prevalence of atrial fibrillation was 5% in patients aged 60 to 70 years, 14% in patients aged 71 to 80 years, 13% in patients aged 81 to 90 years, and 22% in patients aged 91 to 103 years (P < .0001). Mean follow-up was 31 +/- 18 months in patients with atrial fibrillation and 44 +/- 27 months in patients with sinus rhythm (P = .0001). Previous TE stroke occurred in 123 of 283 patients (43%) with atrial fibrillation and in 431 of 1818 patients (24%) with sinus rhythm (P < .0001). New TE stroke occurred in 131 of 283 patients (46%) with atrial fibrillation and in 303 of 1818 patients (17%) with sinus rhythm (P < .0001). The log-rank test showed that patients with atrial fibrillation had a significantly higher probability of developing new TE stroke than those with sinus rhythm (P < .0001). The multivariate Cox regression model showed that independent risk factors for new TE stroke were male sex (relative risk = 1.3), prior TE stroke (relative risk = 3.1), and atrial fibrillation (relative risk = 3.3).

CONCLUSIONS

Atrial fibrillation, prior TE stroke, and male sex are independent risk factors for the development of new TE stroke in older patients.

Stroke is an emergency

Stroke is an emergency. Ischemic stroke is similar to myocardial infarction in that the pathogenesis is loss of blood supply to the tissue, which can result in irreversible damage if blood flow is not restored quickly. Public education is needed to emphasize the warning signs of stroke. Patients should seek medical help immediately, using emergency transport systems. Therapy geared toward minimizing the damage from an acute stroke should be started without delay in the emergency room. This includes measures to protect brain tissue, support perfusion pressure, and minimize cerebral edema. Strategies for improving recovery should also begin immediately. All major medical centers need stroke teams and stroke units. Stroke prevention should be given high priority as a public health strategy. Risk factor management should be part of general health care and should begin in childhood, with emphasis on nutrition, exercise, weight control, and avoidance of tobacco. Health screening and early treatment of hypertension and hypercholesterolemia has decreased the incidence of stroke and heart disease, but these efforts need to be expanded to reach all segments of the population. Basic research has opened the door to new therapies aimed at re-establishing blood flow and limiting tissue damage. Clinical trials have already led to changes in stroke prevention, including studies of carotid endarterectomy and ticlopidine and warfarin therapy (for patients with atrial fibrillation). Trials in progress are testing the usefulness of ancrod, neuroprotective agents, antioxidant agents, anti-inflammatory agents, low-molecular-weight heparin, thrombolytic drugs, and angioplasty. Any delay starting therapy after an acute stroke will result in progressive, irreversible loss of brain tissue. Clinicians should remember that for a stroke patient, time is brain tissue.

Usefulness of M-mode, 2-dimensional, and Doppler echocardiography in the diagnosis, prognosis, and management of valvular aortic stenosis, aortic regurgitation, and mitral annular calcium in older patients

OBJECTIVE

To review the diagnosis, prognosis, and management of valvular aortic stenosis, aortic regurgitation, and mitral annular calcium (MAC) with emphasis on older persons.

DATA SOURCES

A computer-assisted search of the English-language literature (MEDLINE database) followed by a manual search of the bibliographies of pertinent articles.

STUDY SELECTION

Studies on the diagnosis, prognosis, and management of valvular aortic stenosis, aortic regurgitation, and MAC were screened for review. Studies in older persons and recent studies were emphasized.

DATA EXTRACTION

Pertinent data were extracted from the reviewed articles. Emphasis was on studies involving older persons. Relevant articles were reviewed in depth.

DATA SYNTHESIS

Available data about the diagnosis, prognosis, and management of valvular aortic stenosis, aortic regurgitation, and MAC with emphasis on studies involving older persons were summarized.

CONCLUSIONS

Valvular aortic stenosis, aortic regurgitation, and MAC are degenerative cardiac disorders which are common in older people. The presence and severity of these cardiac disorders are diagnosed by M-mode, 2-dimensional, and Doppler echocardiography. M-mode, 2-dimensional, and Doppler echocardiographic techniques are also very useful in the prognosis and management of these cardiac disorders in older persons.

Mitral valve calcification as an index of left ventricular dysfunction in patients with end-stage renal disease on peritoneal dialysis

OBJECTIVE

To determine whether mitral valve or anulus calcification (MC) in patients with end-stage renal disease is associated with abnormalities of left ventricular (LV) structure and function, cardiac characteristics of 55 patients undergoing continuous ambulatory peritoneal dialysis (CAPD) with (n = 26; age: 59 +/- 10 years) vs without (n = 29; age: 58 +/- 12 years) MC were analyzed using echocardiography and Doppler echocardiography. Sclerosis of the mitral valve anulus was detected in 18 (7 women, 11 men; age: 58 +/- 10 years) patients, sclerosis of mitral valve leaflets in 24 (13 women, 9 men; age: 59 +/- 10 years) patients. Patients with MC had higher systolic arterial blood pressure before initiation of dialysis therapy (191/104 mm Hg vs 173/94 mm Hg; p < 0.05) and higher calcium-phosphorus products (55 +/- 13 vs 42 +/- 16; p < 0.05) during CAPD therapy than those without MC. Neither prevalence nor severity of MC was related to dialysis duration or patient age. Systolic LV function was reduced (ejection fraction: 58 +/- 12 percent vs 65 +/- 13 percent; p < 0.05) and LV end-diastolic diameters were dilated (54 +/- 5 vs 50 +/- 8 mm; p < 0.05) in patients with MC. Left atrial dilatation (73 percent vs 31 percent; p < 0.005) and mitral valve regurgitation (65 percent vs 21 percent; p < 0.001) were more frequent in patients with vs those without MC. Excluding patients with significant mitral regurgitation from pulsed Doppler analysis, diastolic LV function was comparably impaired in patients with vs those without MC (maximal early/atrial filling velocity ratio: 0.77 +/- 0.25 vs 0.75 +/- 0.22; atrial filling fraction: 47 +/- 10 percent vs 48 +/- 11 percent; p = NS). The presented data suggest that MC follows long-standing and severe arterial hypertension before start of dialysis therapy. Therefore, effective blood pressure control in the predialysis period may be a tool to prevent these lesions. MC has clinical significance as a marker of LV dilatation and reduced LV systolic function in patients with chronic CAPD.

Transesophageal echocardiography as a tool in the evaluation of patients with embolic disorders

TEE has become one of the most powerful tools for evaluating patients with unexplained stroke, TIA, and peripheral and pulmonary embolization. This is especially encouraging in view of the previously disappointing results of TTE in these patients. In addition to the dramatic results in terms of clot visualization and the other intracardiac sources of embolization described previously, a new extracardiac source has been identified, namely protruding atheromas in the thoracic aorta. These atheromas have been seen for the first time because of the new diagnostic window that has been opened by the development of TEE. Their recognition and follow-up may lead to information that will change the approach to a significant number of patients with embolic ischemic episodes.

Progression of valvular sclerosis in end-stage renal disease treated by long-term peritoneal dialysis

While patients with end-stage renal disease treated by intermittent hemodialysis have frequent and progressive valve disease, nothing is known of the prevalence and course of valvular abnormalities in patients treated with continuous ambulatory peritoneal dialysis (CAPD). Therefore, valves of 24 CAPD patients (ages 55 +/- 11 years; CAPD duration: 29 +/- 28 months) were studied in a prospective echocardiographic and Doppler echocardiographic follow-up analysis over 35 months. Most frequent findings were sclerosis of the aortic annulus (100% at both assessments) and of the anterior mitral valve leaflet (first vs. follow-up assessment: 88 vs. 96%). Sclerosis of the mitral valve annulus (58% vs. 63%), right coronary (54 vs. 63%) and noncoronary (50 vs. 67%) cuspis of the aortic valve and of the posterior mitral valve leaflet (25 vs. 50%) were less frequent but tended to be progressive (p = NS). The moderate form of mitral and aortic valve sclerosis was more frequent than the severe form (p < 0.01 each) at both assessments. Patients with progressive valve disease were older (60 +/- 9 vs. 50 +/- 11 years; p < 0.025) and had a higher frequency angina pectoris than those without a progression (5 vs. 0 patients; p < 0.05). The number of patients with regular sinus rhythm decreased (from 22 to 16; p < 0.03), atrial fibrillation developed in four patients, atrioventricular node rhythm following atrioventricular conduction defect developed in one patient, and atrioventricular conduction defect required implantation of a pacemaker in one patient.(ABSTRACT TRUNCATED AT 250 WORDS)