Relations of inflammation and novel risk factors to valvular calcification

Atherosclerosis, calcific aortic valve disease and mitral annular calcification: same or different?

There are similarities in the pathophysiologic mechanisms of atherosclerosis, calcific aortic valve disease (CAVD) and mitral annular calcification (MAC), however, medical treatment to slow or stop the progression of CAVD or MAC has been more elusive as compared to atherosclerosis. Atherosclerosis and CAVD share common demographic, clinical, protein, and genetic factors even more so than with MAC, which supports the possibility of shared medical therapies, though abrogating calcific extracellular vesicle shedding could be a common target for all three conditions. Herein, we summarize the overlapping and distinct pathways for further investigation, as well as key areas where additional research is needed.

Estimation of the proportion of cardiovascular disease cases in France attributable to high concentrations of low-density lipoprotein cholesterol

BACKGROUND

Elevated concentrations of low-density lipoprotein cholesterol (LDL-C) are highly prevalent and are associated with the development of cardiovascular diseases.

AIM

To estimate the proportion of cardiovascular disease cases attributable to high concentrations of LDL-C (population attributable fraction [PAF]) in France in 2017, based on the most recent individual data on LDL-C, and the attributable burden on hospitalizations and death.

METHODS

We estimated the PAF of high LDL-C concentrations for ischaemic heart disease (IHD), ischaemic stroke and aortic valve stenosis (AVS). Distributions of LDL-C concentrations were obtained from the most recent French health examination representative survey (ESTEBAN). The relative risks of each disease per 1-mmol/L increase in blood LDL-C were obtained either from the most appropriate meta-analyses or from Mendelian randomization.

RESULTS

The PAF of high LDL-C concentrations varied between 44.2% (95% CI 24.6%-60.5%) for IHD-related death and 49.4% (95% CI 35.6-60.8%) for IHD-related years-of-life lost (YLL), 22.5% (95% CI 0.0-43.3%) and 25.5% (95% CI 11.6-36.8%) for ischaemic stroke indicators, and 29.0% (95% CI 8.6-45.4%) and 29.3% (95% CI 8.4-45.6%) for AVS indicators. Overall, 230,000 hospitalizations, 1,303,000 prevalent cases and 23,000 deaths were estimated to be attributable to high LDL-C concentrations, with most cases related to IHD. PAFs were similar across sex and cardiovascular diseases, whereas PAF strongly varied with age for IHD and ischaemic stroke, with PAF reaching 80.6% (95% CI 55.3-92.7%) and 60.9% (95% CI 33.8-80.8%), respectively, in the group aged 35-44 years.

CONCLUSION

The high estimated PAF of elevated LDL-C concentrations for IHD, ischaemic stroke and AVS support the urgent need to reduce the prevalence of hypercholesterolaemia in this French population.

The effect of immunomodulatory drugs on aortic stenosis: a Mendelian randomisation analysis

There are currently no approved pharmacological treatment options for aortic stenosis (AS), and there are limited identified drug targets for this chronic condition. It remains unclear whether inflammation plays a role in AS pathogenesis and whether immunomodulation could become a therapeutic target. We evaluated the potentially causal association between inflammation and AS by investigating the genetically proxied effects of tocilizumab (IL6 receptor, IL6R, inhibitor), canakinumab (IL1β inhibitor) and colchicine (β-tubulin inhibitor) through a Mendelian randomisation (MR) approach. Genetic proxies for these drugs were identified as single nucleotide polymorphisms (SNPs) in the gene, enhancer or promoter regions of IL6R, IL1β or β-tubulin gene isoforms, respectively, that were significantly associated with serum C-reactive protein (CRP) in a large European genome-wide association study (GWAS; 575,531 participants). These were paired with summary statistics from a large GWAS of AS in European patients (653,867 participants) to then perform primary inverse-variance weighted random effect and sensitivity MR analyses for each exposure. This analysis showed that genetically proxied tocilizumab was associated with reduced risk of AS (OR 0.56, 95% CI 0.45-0.70 per unit decrease in genetically predicted log-transformed CRP). Genetically proxied canakinumab was not associated with risk of AS (OR 0.80, 95% CI 0.51-1.26), and only one suitable SNP was identified to proxy the effect of colchicine (OR 34.37, 95% CI 1.99-592.89). The finding that genetically proxied tocilizumab was associated with reduced risk of AS is concordant with an inflammatory hypothesis of AS pathogenesis. Inhibition of IL6R may be a promising therapeutic target for AS management.

High lipoprotein(a) levels and mitral valve disease: A systematic review

AIMS

The role of lipoprotein(a) [Lp(a)] as a possibly causal risk factor for atherosclerotic artery disease and aortic valve stenosis has been well established. However, the information available on the association between Lp(a) levels and mitral valve disease is limited and controversial. The main objective of the present study was to assess the association between Lp(a) levels and mitral valve disease.

DATA SYNTHESIS

This systematic review was performed according to PRISMA guidelines (PROSPERO CRD42022379044). A literature search was performed to detect studies that evaluated the association between Lp(a) levels or single-nucleotide polymorphisms (SNPs) related to high levels of Lp(a) and mitral valve disease, including mitral valve calcification and valve dysfunction. Eight studies including 1,011,520 individuals were considered eligible for this research. The studies that evaluated the association between Lp(a) levels and prevalent mitral valve calcification found predominantly positive results. Similar findings were reported in two studies that evaluated the SNPs related to high levels of Lp(a). Only two studies evaluated the association of Lp(a) and mitral valve dysfunction, showing contradictory results.

CONCLUSIONS

This research showed disparate results regarding the association between Lp(a) levels and mitral valve disease. The association between Lp(a) levels and mitral valve calcification seems more robust and is in line with the findings already demonstrated in aortic valve disease. New studies should be developed to clarify this topic.

Atherogenic index of plasma is an independent predictor of mitral annular calcification

BACKGROUND

In the latest reports, atherogenic indices have been related to acute coronary syndromes, stable coronary artery disease, heart failure and future cardiac events. Conventional atherosclerosis risk factors have been associated with mitral annular calcification (MAC), but data on the relationship between atherogenic indices and MAC are lacking. We aimed to investigate a possible relationship between MAC and atherogenic indices.

METHODS

In total 741 patients (n = 427 with MAC and n = 314 without MAC) who were examined in our cardiology clinic from February 2016 to October 2021 were recruited in the study. Mitral annular calcification was diagnosed by transthoracic 2-dimensional echocardiography. The atherogenic coefficient (AC), Castelli risk index 1 (CRI-1), Castelli risk index 2 (CRI-2) and atherogenic index of plasma (AIP) were calculated by utilizing standard lipid test values.

RESULTS

There was no statistically significant difference in sex, age, diabetes and hypertension status between the patient and the control groups. Serum triglyceride level, AIP, Hs-CRP, smoking and BMI were independently significantly associated with MAC in multiple regression analysis (p < 0.001).

CONCLUSION

Higher AIP was related to the existence of MAC and also predict the presence of MAC independently. Studies evaluating the modification of these indices are needed.

Prognostic value of left atrial volume index in degenerative mitral stenosis

Purpose

Degenerative mitral stenosis (DMS) is associated with a poor prognosis. Although mean transmitral gradient (TMG) has shown a good correlation with outcome, little is known about the association between other echocardiographic parameters and prognosis in patients with DMS. The current study aimed to evaluate the prognostic value of left atrial volume index (LAVI) in patients with DMS.

Methods

A total of 155 patients with DMS (72[63–80] years, 67% female) were included. The population was divided according to LAVI: normal-sized LAVI (LAVI ≤ 34 ml/m2); and enlarged LAVI (> 34 ml/m2).

Results

Patients with enlarged LAVI had a higher left ventricular mass index (120[96–146] vs. 91[70–112] g/m2 p < 0.001), as well as a higher prevalence of significant mitral regurgitation and severe aortic stenosis (23% vs. 10% p = 0.046 and 38% vs. 15% p=0.001, respectively) compared to patients with normal-sized LAVI. During a median follow-up of 25 months, 56 (36%) patients died. Patients with enlarged LAVI had worse prognosis compared to patients with normal-sized LAVI (p = 0.026). In multivariable Cox regression model, an enlarged LAVI was independently associated with all-cause mortality (HR 2.009, 95% CI 1.040 to 3.880, P = 0.038).

Conclusion

An enlarged LAVI (> 34 ml/m2) is significantly associated with excess mortality in patients with DMS. After adjusting for potential confounders, an enlarged LAVI was the only parameter that remained independently associated with prognosis.

Prevalence and Natural History of Mitral Annulus Calcification and Related Valve Dysfunction

OBJECTIVE

To evaluate the prevalence and natural history of mitral annulus calcification (MAC) and associated mitral valve dysfunction (MVD) in patients undergoing clinically indicated echocardiography.

METHODS

A retrospective review was conducted of all adults who underwent echocardiography in 2015. Mitral valve dysfunction was defined as mitral regurgitation or mitral stenosis (MS) of moderate or greater severity. All-cause mortality during 3.0 (0.4 to 4.2) years of follow-up was compared between groups stratified according to the presence of MAC or MVD.

RESULTS

Of 24,414 evaluated patients, 5502 (23%) had MAC. Patients with MAC were older (75±10 years vs 60±16 years; P<.001) and more frequently had MVD (MS: 6.6% vs 0.5% [P<.001]; mitral regurgitation without MS: 9.5% vs 6.1% [P<.001]). Associated with MS in patients with MAC were aortic valve dysfunction, female sex, chest irradiation, renal dysfunction, and coronary artery disease. Kaplan-Meier 1-year survival was 76% in MAC+/MVD+, 87% in MAC+/MVD-, 86% in MAC-/MVD+, and 92% in MAC-/MVD-. Adjusted for age, diabetes, renal dysfunction, cancer, chest irradiation, ejection fraction below 50%, aortic stenosis, tricuspid regurgitation, and pulmonary hypertension, MAC was associated with higher mortality during follow-up (adjusted hazard ratio, 1.40; 95% CI, 1.31 to 1.49; P<.001); MVD was associated with even higher mortality in patients with MAC (adjusted hazard ratio, 1.79; 95% CI, 1.58 to 2.01; P<.001). There was no significant interaction between MAC and MVD for mortality (P=.10).

CONCLUSION

In a large cohort of adults undergoing echocardiography, the prevalence of MAC was 23%. Mitral valve dysfunction was more than twice as prevalent in patients with MAC. Adjusted mortality was increased in patients with MAC and worse with both MAC and MVD.

Lymphocyte-to-monocyte ratio in predicting the calcific aortic valve stenosis in a Chinese case-control study

Aim: This study examined the role of lymphocyte-to-monocyte ratio (LMR), an inflammatory biomarker, in predicting the severity of calcific aortic valve stenosis (CAVS) in a Chinese case-control study. Results: The LMR significantly decreased in the patients with CAVS compared with healthy controls. An inverse correlation was observed between the severity of stenosis and LMR in the patients. Additionally, the LMR was identified in the multivariate analysis as an independent predictor of severe CAVS. Conclusion: This study provides evidence of an inverse correlation between the severity of CAVS and LMR. LMR could potentially be applied as an independent predictor of severe CAVS and could be incorporated into a novel predictive model.

Mitral Annular Calcification: Association with Atherosclerosis and Clinical Implications

PURPOSE OF REVIEW

This review summarizes the pathophysiology of mitral annular calcification (MAC) with recent findings and current strategies for diagnosis and treatment.

RECENT FINDINGS

Major factors in MAC development seem to be shear stress of the flow past the mitral valve, local inflammation, and dysregulation in regulators of mineral metabolism. MAC itself poses daunting technical challenges. Implanting a valve on top of the calcium bar might lead to paravalvular leak (PVL) that is less likely to heal. Annular decalcification allows for better valve seating and potentially better healing and less PVL. This, however, comes with the risk for catastrophic atrioventricular groove disruption. MAC can be sharply dissected with the scalpel; the annulus can be reconstructed with the autologous pericardium. Transcatheter mitral valve replacement is a promising approach in the treatment of patients who are deemed high-risk surgical candidates with severe MAC. MAC is a multifactorial disease that has some commonalities with atherosclerosis, mainly regarding lipid accumulation and calcium deposition. It is of great clinical importance, being a risk marker of cardiovascular events (including sudden death) and, with its progression, can have a negative impact on patients' lives.

Prevalence and risk factors of aortic stenosis and aortic sclerosis: a 21-year follow-up of middle-aged men

Introduction. There is limited knowledge about factors associated with the development of aortic stenosis. This study aimed to examine the prevalence of aortic sclerosis or stenosis in 71-years-old men and determine which risk factors at 50 years of age predict the development of aortic sclerosis or aortic stenosis. Methods. A random sample of Swedish men from the general population, born in 1943 (n = 798) were followed for 21 years. Data on clinical characteristics and laboratory values were collected in 1993. An echocardiography was performed in 2014. We used logistic regression to examine the association between baseline data and the outcome. Results. Echocardiography was performed in 535 men, and aortic sclerosis or aortic stenosis was diagnosed in 27 (5.0%). 14 persons developed aortic stenosis (2.6%). Among men with aortic sclerosis or aortic stenosis, 29.6% were obese. In multivariable stepwise regression model, body mass index (odds ratio per unit increase 1.23 (95% CI 1.10-1.38; p = .0003)) and hypercholesterolemia, combined with high sensitive C-reactive protein (odds ratio versus all other 2.66 (1.18-6.00; p = .019)) were significantly associated with increased risk of developing aortic sclerosis or aortic stenosis. Body mass index was the only factor significantly associated with a higher risk of developing aortic stenosis. Conclusion. The prevalence of either aortic sclerosis or aortic stenosis was 5% and of aortic stenosis 2.6%. Obesity and hypercholesterolemia combined with elevated high sensitive C-reactive protein at the age of 50 predicted the development of degenerative aortic sclerosis or stenosis, whilst only obesity was correlated with the occurrence of aortic stenosis.

Aortic stenosis and diabetes mellitus: An ominous combination

Aortic stenosis and diabetes mellitus are both progressive diseases which, if left untreated, result in significant morbidity and mortality. There is evidence that the prevalence of diabetes is substantially increased in patients with aortic stenosis and those with diabetes have increased rates of progression from mild to severe aortic stenosis. There are good data supporting the hypothesis that aortic stenosis and diabetes mellitus are associated with diabetes mellitus being detrimental towards the quality of life and survival of patients. Thus, a thorough understanding of the pathogenesis of both of these disease processes and the relationship between them aids in designing appropriate preventive and therapeutic approaches. This review aims to give a comprehensive and up-to-date insight into the influence of diabetes mellitus on patients with degenerative aortic stenosis, as well as the prognosis and therapeutic approach to these patients.

Causes and consequences of cardiac fibrosis in patients referred for surgical aortic valve replacement

Aims

Cardiac fibrosis is associated with left ventricular (LV) remodelling and contractile dysfunction in aortic stenosis (AS). The fibrotic process in this condition is still unclear. The aim of this study was to determine the role of both local and systemic inflammation as underlying mechanisms of LV fibrosis and contractile dysfunction. The diagnostic values of 2D‐strain echocardiography and serum biomarkers in the evaluation of cardiac fibrosis in this condition were assessed through correlation analyses.

Methods and results

Patients with AS referred for surgical valve replacement were prospectively and consecutively included. They all had a comprehensive echocardiography including 2D strain. Blood samples were collected to measure cytokines and inflammatory biomarkers using Luminex bead‐based assays. A per‐surgical myocardial biopsy of the basal antero‐septal segment (S1) was performed. Serial sections of each biopsy were stained with Sirius red. Digital image analysis was used to quantify fibrosis. Immunostainings using specific antibodies against macrophage, glycoprotein (gp) 130, and interleukin 6 (IL‐6) were also performed. Patients were divided into tertiles reflecting the severity of fibrosis: mild, moderate, and severe load (TF1 to TF3). The mean age of the 58 included patients was 73 ± 11 years. Twenty‐four (43%) were in New York Heart Association III–IV. Mean aortic valve area was 0.8 ± 0.2 cm². Mean aortic stenosis peak velocity and mean gradient were respectively 4.5 ± 0.8 m/s and 54 ± 15 mmHg. The mean LV ejection fraction was 54 ± 12%, and the global LV longitudinal strain was −15 ± 4%. The mean S1 strain, corresponding to the biopsied region, was −10 ± 6% and was strongly correlated to fibrosis load (R = 0.83, P < 0.0001). TF3 was associated with higher mortality (P = 0.009), higher serum C‐reactive protein and IL‐6, and lower gp130 compared with the other tertiles (P < 0.05). IL‐6 and gp130 were expressed in the heart and respectively in the plasma membrane of macrophages and in the cytoplasm of both macrophages and cardiomyocytes. During follow‐up, three patients died and were all in the third fibrosis tertile.

Conclusions

We found a positive correlation between elevated inflammatory markers and degree of fibrosis load. These two parameters were associated with worse outcomes in patients with severe AS. Our results may be of interest especially in patients for whom a transcatheter aortic valve implantation is indicated and myocardial biopsy is not possible. Strategies aiming at preventing inflammation might be considered to decrease or limit the progression of cardiac fibrosis in patients followed for AS.

The relation between echocardiographic epicardial fat thickness and mitral annular calcification

Background

Mitral annular calcification (MAC) is associated with several cardiovascular disorders including coronary artery disease (CAD), atrial fibrillation, heart failure, ischemic stroke and increased mortality. Epicardial fat thickness (EFT) has strong correlation with obesity, CAD, insulin resistance, metabolic syndrome, hypertension, diabetes mellitus, and atherosclerosis. There are strong similarities between EFT and MAC from the aspect of risk factors and pathogenesis.

Objective

In this study we aimed to investigate the EFT in patients with MAC.

Methods

The study group consisted of 78 patients with MAC. An age, gender and body mass index matched control group consisted of 47 subjects who admitted to echocardiography laboratory due to suspicion of organic heart disease and eventually found to be free of MAC. We measured EFT in patients with MAC and control subjects.

Results

EFT was significantly higher in patients with MAC than in control subjects (5.7±0.9 vs. 4.4±0.6 mm respectively; P< 0.001). Correlation analysis indicated that EFT was positively correlated with presence of MAC (p<0.001, r=0.597).

Conclusion

We showed that EFT was significantly elevated in patients with MAC and it was positively correlated with MAC.

Left ventricular hypertrophy is a possible biomarker for early mortality after type B aortic dissection

OBJECTIVE

Data regarding the cardiac abnormalities associated with Stanford type B aortic dissection (TBAD) and whether these abnormalities are related to outcomes are limited. We describe the prevalence of cardiac abnormalities in patients with TBAD as detected by echocardiography.

METHODS

This retrospective review included patients with TBAD presenting between 1990 and 2016. Echocardiograms performed within 6 weeks of acute TBAD were reviewed. Cardiac function, valve abnormalities, and stigmata of hypertensive heart disease including left ventricular hypertrophy (LVH) were ascertained. Characteristics of patients who did and did not receive echocardiograms were compared. Outcomes of patients with and without evidence of LVH on echocardiography were also compared.

RESULTS

Of 239 patients with TBAD, 90 had echocardiograms performed within 6 weeks of acute TBAD (74% male; mean age, 57.8 ± 13.2 years). Echocardiograms were obtained at a median of 2 days (range, 0-41 days) from acute TBAD. Patients who had echocardiograms were more likely to present with malperfusion (28% vs 14%; P < .01) and had a trend toward increased operative repair during the subacute phase (17.4% vs 9.5%; P = .07) compared with patients who did not receive an echocardiogram. A majority of patients (57%) had at least mild LVH, including 39% of patients without a prior diagnosis of hypertension. Fibrocalcific changes associated with hypertension, including aortic sclerosis and mitral annular calcification, were noted in 40% and 11% of the patients, respectively. Among patients with LVH, there was a trend toward higher all-cause mortality (35% vs 23%; P = .21) and a younger age at death (58 ± 14 years vs 66 ± 13 years; P = .19) despite a similar age at TBAD onset. In a multivariable analysis controlling for age, sex, and admission estimated glomerular filtration rate, LVH independently predicted all-cause mortality (hazard ratio, 2.38; 95% confidence interval, 1.02-5.56; P = .04).

CONCLUSIONS

LVH and other findings of hypertensive heart disease are common in patients with TBAD. LVH predicted all-cause mortality after TBAD in this small group of patients. Further exploration of the relationship between the chronic effects of hypertension and using LVH as an objective biomarker to risk stratify patients with TBAD and long-term outcomes after TBAD is warranted.

Aortic stenosis is a risk factor for all-cause mortality in patients on dialysis: a multicenter prospective cohort analysis

Background

Aortic stenosis (AS) is common in patients on dialysis as well as in the general population. AS leads to difficulty with dialysis therapy because of unstable conditions such as intradialytic hypotension due to low cardiac output. However, the precise morbidity rates and risk factors of AS in patients on dialysis are unknown. Moreover, there are no large-scale observational studies regarding the association between AS in patients on dialysis and mortality. Therefore, we will investigate whether morbidity of AS in patients on dialysis is associated with mortality.

Methods

This is a multicenter prospective cohort analysis in the Tokai region of Japan. The 75 participating centers in this study will enroll approximately 2400 patients during 12 months, with or without AS. We started enrollment in July 2017 and will follow patents until June 2023. Transthoracic echocardiography will be performed to evaluate aortic valve. Parameters used for evaluation of aortic valve are mean pressure gradient between left ventricle and ascending aorta, aortic valve area, and maximum aortic jet velocity. We will diagnose AS using the criteria based on the 2014 American Heart Association/ American College of Cardiology Guideline. We will also perform transthoracic echocardiography at 12, 24, 36, 48, and 60 months. Survival prognosis and CV events will be determined at the end of June 2019, 2020, 2021, 2022, and 2023. Development of AS will be also evaluated as new onset or annual change in AS parameters. We will classify patients based on the presence or absence of AS and the stages of AS and will compare outcomes. Study outcomes will include the following: 1) all-cause mortality rates; 2) incidence of cardiovascular (CV) events; 3) CV-related mortality rates; 4) infection-related mortality rates; 5) new onset or development of AS.

Discussion

We will consider the following hypotheses in this study, among others: The prevalence of AS is higher in dialysis patients; new onset and development of AS are associated with factors that are specific for dialysis, such as hyperphosphatemia, hyperparathyroidism, and medication; and outcomes in AS patients are poorer than in patients without AS at baseline.

Trial registration

UMIN000026756, Registered March 29 2017.

Predictive value of platelet-to-lymphocyte ratio in severe degenerative aortic valve stenosis

Background:

Aortic valve stenosis (AVS) is the most common cause of left ventricular outflow obstruction, and its prevalence among elderly patients causes a major public health burden. Recently, platelet-to-lymphocyte ratio (PLR) has been recognized as a novel prognostic biomarker that offers information about both aggregation and inflammation pathways. Since PLR indicates inflammation, we hypothesized that PLR may be associated with the severity of AVS due to chronic inflammation pathways that cause stiffness and calcification of the aortic valve.

Materials and Methods:

We retrospectively enrolled 117 patients with severe degenerative AVS, who underwent aortic valve replacement and 117 control patients in our clinic. PLR was defined as the absolute platelet count divided by the absolute lymphocyte count. Severe AVS was defined as calcification and sclerosis of the valve with a mean pressure gradient of >40 mmHg.

Results:

PLR was 197.03 ± 49.61 in the AVS group and 144.9 ± 40.35 in the control group, which indicated a statistically significant difference (P < 0.001). A receiver operating characteristic (ROC) curve analysis demonstrated that PLR values over 188 predicted the severity of aortic stenosis with a sensitivity of 87% and a specificity of 70% (95% confidence interval = 0.734–0.882; P < 0.001; area under ROC curve: 0.808).

Conclusion:

We suggest that the level of PLR elevation is related to the severity of degenerative AVS, and PLR should be used to monitor patients' inflammatory responses and the efficacy of treatment, which will lead us to more closely monitor this high-risk population to detect severe degenerative AVS at an early stage.

Association of inflammatory, lipid and mineral markers with cardiac calcification in older adults

OBJECTIVE

Calcification of the aortic valve and adjacent structures involves inflammatory, lipid and mineral metabolism pathways. We hypothesised that circulating biomarkers reflecting these pathways are associated with cardiac calcification in older adults.

METHODS

We investigated the associations of various biomarkers with valvular and annular calcification in the Cardiovascular Health Study. Of the 5888 participants, up to 3585 were eligible after exclusions for missing biomarker, covariate or echocardiographic data. We evaluated analytes reflecting lipid (lipoprotein (Lp) (a), Lp-associated phospholipase A₂ (LpPLA₂) mass and activity), inflammatory (interleukin-6, soluble (s) CD14) and mineral metabolism (fetuin-A, fibroblast growth factor (FGF)-23) pathways that were measured within 5 years of echocardiography. The relationships of plasma biomarkers with aortic valve calcification (AVC), aortic annular calcification (AAC) and mitral annular calcification (MAC) were assessed with relative risk (RR) regression.

RESULTS

Calcification was prevalent: AVC 59%, AAC 45% and MAC 41%. After adjustment, Lp(a), LpPLA₂ mass and activity and sCD14 were positively associated with AVC. RRs for AVC per SD (95% CI) were as follows: Lp(a), 1.051 (1.022 to 1.081); LpPLA₂ mass, 1.036 (1.006 to 1.066) and LpPLA₂ activity, 1.037 (1.004 to 1.071); sCD14, 1.039 (1.005 to 1.073). FGF-23 was positively associated with MAC, 1.040 (1.004 to 1.078) and fetuin-A was negatively associated, 0.949 (0.911 to 0.989). No biomarkers were significantly associated with AAC.

CONCLUSION

This study shows novel associations of circulating FGF-23 and fetuin-A with MAC, and LpPLA₂ and sCD14 with AVC, confirming that previously reported for Lp(a). Further investigation of Lp and inflammatory pathways may provide added insight into the aetiology of AVC, while study of phosphate regulation may illuminate the pathogenesis of MAC.

Extra-coronary calcification (aortic valve calcification, mitral annular calcification, aortic valve ring calcification and thoracic aortic calcification) in HIV seropositive and seronegative men: Multicenter AIDS Cohort Study

INTRODUCTION

Previous studies have demonstrated an association between HIV infection and coronary artery disease (CAD); little is known about potential associations between HIV infection and extra-coronary calcification (ECC).

METHODS

We analyzed 621 HIV infected (HIV+) and 384 HIV uninfected (HIV-) men from the Multicenter AIDS Cohort Study who underwent non-contrast computed tomography (CT) from 2010-2013. Agatston scores were calculated for mitral annular calcification (MAC), aortic valve calcification (AVC), aortic valve ring calcification (AVRC), and thoracic aortic calcification (TAC). The associations between HIV infection and the presence of each type of ECC (score > 0) were evaluated by multivariable logistic regression. We also evaluated the association of ECC with inflammatory biomarker levels and coronary plaque morphology.

RESULTS

Among HIV+ and HIV- men, the age-standardized prevalences were 15% for TAC (HIV+ 14%/HIV- 16%), 10% for AVC (HIV+ 11%/HIV- 8%), 24% for AVRC (HIV+ 23% HIV- 24%), and 5% for MAC (HIV+ 7%/HIV- 3%). After adjustment, HIV+ men had 3-fold greater odds of MAC compared to HIV- men (OR = 3.2, 95% CI: 1.5-6.7), and almost twice the odds of AVC (1.8, 1.1-2.9). HIV serostatus was not associated with TAC or AVRC. AVRC was associated with higher Il-6 and sCD163 levels. TAC was associated with higher ICAM-1, TNF-α RII, and Il-6 levels. AVC and AVRC calcification were associated with presence of non-calcified plaque in HIV+ but not HIV- men.

CONCLUSION

HIV infection is an independent predictor of MAC and AVC. Whether these calcifications predict mortality in HIV+ patients deserves further investigation.

Heart valve calcification in patients with type 2 diabetes and nonalcoholic fatty liver disease

PURPOSE

Aortic valve sclerosis (AVS) and mitral annulus calcification (MAC) are two powerful predictors of adverse cardiovascular outcomes in patients with type 2 diabetes, but the etiology of valvular calcification is uncertain. Nonalcoholic fatty liver disease (NAFLD) is an emerging cardiovascular risk factor and is very common in type 2 diabetes, but whether NAFLD is associated with valvular calcification in this group of patients is presently unknown.

METHODS

We undertook a cross-sectional study of 247 consecutive type 2 diabetic outpatients with no previous history of heart failure, valvular heart diseases (aortic stenosis, mitral stenosis, moderate or severe aortic and mitral regurgitation) or hepatic diseases. Presence of MAC and AVS was detected by echocardiography. NAFLD was diagnosed by ultrasonography.

RESULTS

Overall, 139 (56.3%) patients had no heart valve calcification (HVC-0), 65 (26.3%) patients had one valve affected (HVC-1) and 43 (17.4%) patients had both valves affected (HVC-2). 175 (70.8%) patients had NAFLD and the prevalence of this disease markedly increased in patients with HVC-2 compared with either HVC-1 or HVC-0 (86.1% vs. 83.1% vs. 60.4%, respectively; p < 0.001). NAFLD was significantly associated with AVS and/or MAC (unadjusted-odds ratio 3.51, 95% CI 1.89-6.51, p < 0.001). Adjustments for age, sex, waist circumference, smoking, blood pressure, hemoglobin A1c, LDL-cholesterol, kidney function parameters, medication use and echocardiographic variables did not appreciably weaken this association (adjusted-odds ratio 2.70, 95% CI 1.23-7.38, p < 0.01).

CONCLUSIONS

Our results show that NAFLD is an independent predictor of cardiac calcification in both the aortic and mitral valves in patients with type 2 diabetes.

Mitral annular calcification and incident atrial fibrillation in the Multi-Ethnic Study of Atherosclerosis

AIMS

The associations of mitral annular calcification (MAC) with atrial fibrillation (AF) risk factors and related outcomes suggest a possible association between MAC and AF. The aim of this study was to examine the association between MAC and AF in a racially and ethnically diverse population.

METHODS AND RESULTS

This analysis included 6641 participants (mean age 62 ± 10 years; 53% women; 27% Blacks; 22% Hispanics; 12% Chinese-Americans) from the Multi-Ethnic Study of Atherosclerosis (MESA) who were free of clinical cardiovascular disease and AF at baseline. The presence of MAC was defined by cardiac computed tomography (CT) as an Agatston score >0. Atrial fibrillation was ascertained by hospital discharge records and from Medicare claims data until 31 December 2010. Cox regression was used to compute hazard ratios (HRs) and 95% confidence intervals (95% CIs) for the association between MAC and AF. At baseline, 619 (9.3%) participants had MAC. Over a median follow-up of 8.5 years, 308 (4.6%) participants developed AF. In a multivariable adjusted model, MAC was associated with an increased risk of AF (HR = 1.9, 95% CI = 1.5, 2.5). This association was consistent across subgroups of age, sex, race/ethnicity (Whites vs. non-Whites), hypertension, diabetes, and left atrial enlargement. The addition of MAC to the Framingham Heart Study and CHARGE AF risk scores for AF improved the C-statistics from 0.769 to 0.776 (P = 0.038) and 0.788 to 0.792 (P = 0.089), respectively.

CONCLUSION

The presence of MAC was predictive of incident AF in MESA. Potentially, these findings suggest a usefulness of cardiac CT to identify individuals at risk for AF.

Profile of incident chronic kidney disease related-mineral bone disorders in chronic kidney disease Stage 4 and 5: A hospital based cross-sectional survey

Chronic kidney disease related-mineral bone disorder (CKD-MBD) has been poorly studied in pre-dialysis Indian CKD patients. We aimed to study the clinical, biochemical and extra skeletal manifestations of untreated CKD-MBD in pre-dialysis Stage 4 and 5 CKD patients attending nephrology out-patient clinic at a tertiary care hospital in South India. A hospital based cross-sectional survey including, demographic profile, history of CKD-MBD symptoms, measurement of serum calcium, phosphate, parathyroid hormone, 25 hydroxy vitamin D (25(OH) D) and alkaline phosphatase; lateral abdominal X-rays for abdominal aortic calcification (AAC) and echocardiography for valvular calcification (VC) was carried out. Of the 710 patients surveyed, 45% had no CKD-MBD related symptom. Prevalence of hypocalcemia, hyperphosphatemia, hyperparathyroidism (>150 pg/mL) and 25(OH) D levels <30 ng/mL was 66.3%, 59%, 89.3% and 74.7% respectively. Echocardiography was carried out in 471 patients; 96% of whom had VC (calcification score ≥1). Patients with VC were older and had lower 25(OH) D levels than those without. Lateral abdominal X-rays were obtained in 558 patients, 6.8% of whom were found to have AAC, which was associated with older age. Indian patients with incident CKD-MBD have a high prevalence of hypocalcemia, 25(OH) D deficiency and VC even prior to initiating dialysis while AAC does not appear to be common. The association between 25(OH) D deficiency and VC needs further exploration.

Relationship between mean platelet volume and mitral annular calcification

Mitral annular calcification (MAC) is associated with several cardiovascular disorders including coronary artery disease (CAD), atherosclerosis, heart failure, and stroke. MAC and atherosclerosis share similar clinical risk factors for cardiovascular diseases, including age, obesity, hypertension, hyperlipidemia, and diabetes mellitus. The aim of this study was to assess the mean platelet volume (MPV), an indicator of platelet activation in patients with MAC. The study group consisted of 101 patients with MAC. An age, sex, and BMI matched control group was composed of 55 patients who were admitted to the echocardiography laboratory due to suspicion of organic heart disease and eventually found to be free of MAC. We measured platelet indices values in patients and controls. MPV was significantly higher in patients with MAC than in controls (8.9 ± 0.8 versus 8.0 ± 0.9 fl, respectively; P < 0.001) and platelet distribution width (PDW) was significantly higher in patients with MAC than in controls (15.8 ± 1.3 versus 15.0 ± 1.3%, respectively; P < 0.001). MPV was positively correlated with MAC (P < 0.001, r = 0.47), atrial fibrillation (P = 0.01, r = 0.19), left atrial (P = 0.02, r = 0.83) and negatively correlated with platelet count (P = 0.01, r = -0.20). MPV [odds ratio (OR) 3.89; 95% confidence interval (CI) 1.97-7.67; P < 0.0001], and PDW (OR 2.27; 95% CI 1.45-3.55; P < 0.0001) were independently associated with the MAC. We have shown that MPV and PDW were significantly elevated in patients with MAC. MPV was correlated with MAC, atrial fibrillation and left atrial and negatively correlated with platelet count. MPV and PDW were independently associated with MAC.

Mitral annular calcification is associated with pulse wave velocity but not with augmentation index

OBJECTIVE

To investigate the possible relationship between mitral annular calcification (MAC) and arterial stiffness.

SUBJECTS AND METHODS

Forty-two patients (mean age 68 ± 6 years) with MAC and an age-matched control group of 41 individuals (mean age 66 ± 6 years) were studied. Arterial stiffness and wave reflections of the study population were evaluated by using applanation tonometry (SphygmoCor). Aortic pulse wave velocity (PWV) was measured as an index of aortic stiffness. The heart rate-corrected augmentation index (AIx@75) was estimated as a composite marker of wave reflections and arterial stiffness.

RESULTS

Aortic PWV was significantly higher in patients with MAC (12.2 ± 2.3 m/s) than in controls (10.1 ± 1.3 m/s, p = 0.0001). However, AIx@75 was similar between the groups (28 ± 10 vs. 29 ± 10%, p = 0.59). Multivariate analysis involving the whole population revealed that brachial diastolic blood pressure (β = 1.87, p = 0.04) and MAC (β = 0.41, p = 0.0001) were independent determinants of aortic PWV.

CONCLUSION

The data showed that MAC was significantly associated with increased arterial stiffness and that it was an independent determinant of aortic PWV.

Cardiovascular risk factors and mitral annular calcification in type 2 diabetes

OBJECTIVE

Mitral annular calcification (MAC) is a degenerative process of the mitral annulus associated with cardiac disease and stroke. Although thought to be more prevalent in type 2 diabetes (T2DM), MAC remains poorly characterized in this population, due to confounding by renal and cardiac disease. Our goal was to study the risk factors for MAC in a sample of T2DM subjects without renal and cardiac disease.

METHODS

The Penn Diabetes Heart Study (PDHS) is a cross-sectional study of diabetic individuals without clinical cardiovascular or renal disease. We quantified and analyzed MAC Agatston scores in baseline cardiac CTs from 1753 individuals. Logistic and tobit regression were used to assess MAC's relationship with risk factors and coronary artery calcium (CAC).

RESULTS

MAC was present in 12.0% of subjects, with a median Agatston score of 72.3 [Interquartile range (22.2-256.9)]. Older age, female gender, Caucasian race, and longer diabetes duration were independently associated with both the presence and extent MAC even after controlling for CAC; however, hypertension, hyperlipidemia, tobacco use, CRP levels, and other comorbidities were not associated. CAC was strongly associated with MAC [OR of 4.0 (95% CI 2.4-6.6)] in multivariable models.

CONCLUSIONS

Age, female gender, Caucasian race, and diabetes duration were associated with the presence and extent of MAC in T2DM subjects, independent of CAC, which was also strongly associated with MAC. These data suggest that additional mechanisms for MAC formation in diabetics may exist which are distinct from those related to generalized atherosclerosis and deserve further investigation.

Mitral annular calcium, inducible myocardial ischemia, and cardiovascular events in outpatients with coronary heart disease (from the Heart and Soul Study)

We sought to determine whether mitral annular calcium (MAC) is associated with inducible myocardial ischemia and adverse cardiovascular outcomes in ambulatory patients with coronary artery disease (CAD). MAC is associated with cardiovascular disease (CVD) in the general population, but its association with CVD outcomes in patients with CAD has not been evaluated. We examined the association of MAC with inducible ischemia and subsequent cardiovascular events in 1,020 ambulatory patients with CAD who were enrolled in the Heart and Soul Study. We used logistic regression to determine the association of MAC with inducible ischemia and Cox proportional hazards models to determine the association with CVD events (myocardial infarction, heart failure, stroke, transient ischemic attack or death). Models were adjusted for age, gender, race, smoking, history of heart failure, blood pressure, high-density lipoprotein, and estimated glomerular filtration rate. Of the 1,020 participants 192 (19%) had MAC. Participants with MAC were more likely than those without MAC to have inducible ischemia (adjusted odds ratio 2.06, 95% confidence interval 1.41 to 3.01, p = 0.0002). During an average of 6.26 ± 2.11 years of follow-up, there were 310 deaths, 161 hospitalizations for heart failure, 118 myocardial infarctions, and 55 cerebrovascular events. MAC was associated with an increased rate of cardiovascular events (adjusted hazard ratio 1.39, 95% confidence interval 1.08 to 1.79, p = 0.01). In conclusion, we found that MAC was associated with inducible ischemia and subsequent CVD events in ambulatory patients with CAD. MAC may indicate a high atherosclerotic burden and identify patients at increased risk for adverse cardiovascular outcomes.

Relationship Between Cardiac Valvular and Arterial Calcification in Patients with Rheumatoid Arthritis and Systemic Lupus Erythematosus

Objective.

Cardiac valvular calcification has been linked with systemic atherosclerosis in the general population. The prevalence and relationship with arterial calcification in patients with rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) is unknown. We investigated the prevalence of valvular calcification in patients with RA and SLE and its relationship with arterial atherosclerotic calcification.

Methods.

We compared aortic valve calcification (AVC), mitral valve calcification (MVC), and systemic vascular bed calcification using multidetector computed tomography in 110 patients (mean age 46.5 ± 9.4 yrs, 97 women) with RA (n = 58) or SLE (n = 52) and 60 age and sex-matched healthy controls.

Results.

Patients with RA and SLE, combined, had significantly higher prevalence of AVC (21.8% vs 3.3% in controls; p < 0.01), MVC (19.1% vs 0% in controls; p < 0.01), and arterial calcification in different vascular beds (all p < 0.05). AVC was not associated with any specific clinical characteristics, but MVC was associated with older age, hypertension, C-reactive protein level, and duration of disease. The presence of MVC was independently associated with coronary calcification and calcification in any vascular bed upon adjustment with clinical measures.

Conclusion.

Our study demonstrated that cardiac valvular calcification is more prevalent in patients with RA and SLE compared with healthy controls. The presence of MVC, but not AVC, independently predicted the occurrence of premature atherosclerosis with arterial calcification in patients with RA and SLE.

Crystalline ultrastructures, inflammatory elements, and neoangiogenesis are present in inconspicuous aortic valve tissue

Morbidity from calcific aortic valve disease (CAVD) is increasing. Recent studies suggest early reversible changes involving inflammation and neoangiogenesis. We hypothesized that microcalcifications, chemokines, and growth factors are present in unaffected regions of calcific aortic valves. We studied aortic valves from 4 patients with CAVD and from 1 control, using immunohistochemistry, scanning electron microscopy, and infrared spectrography. We revealed clusters of capillary neovessels in calcified (ECC), to a lesser extent in noncalcified (ECN) areas. Endothelial cells proved constant expression of SDF-1 in ECC, ECN, and endothelial cells from valvular surface (ECS). Its receptor CXCR4 was expressed in ECC. IL-6 expression correlated with CXCR4 staining and presence of lymphocytes. VEGF was expressed by ECS, its receptor by ECC and ECN. Crystalline ultrastructures were found on the surface of histologically noncalcified areas (HNCAs), spectrography revealed calcium hydroxylapatite. Our results demonstrate that crystalline ultrastructures are present in HNCAs, undergoing neoangiogenesis in an inflammatory context. These alterations could be an early witness of disease and an opening to therapy.

Aortic stenosis: clinical aspects of diagnosis and management, with 10 illustrative case reports from a 25-year experience

Aortic stenosis (AS) is a chronic, progressive disease predominantly affecting individuals aged over 60 years. Symptoms are the result of progressive left ventricular outflow obstruction, and herald rapid clinical decline and high mortality. Medical therapies for AS remain ineffective; operative valve replacement remains the only effective long-term treatment. We review clinical aspects of diagnosis and management of AS in adults, with attention to the natural history before and after valve replacement, assessment of suspected and established AS, and recommended management in general and in difficult clinical scenarios. We conclude with a series of 10 cases illustrating management of common, uncommon, and challenging clinical scenarios encountered at the University of Washington.

Associations of long-term and early adult atherosclerosis risk factors with aortic and mitral valve calcium

OBJECTIVES

To determine the association of long-term exposure to atherosclerosis risk factors with valvular calcification.

BACKGROUND

Traditional atherosclerosis risk factors have been associated with aortic and mitral valve calcium in cross-sectional studies, but long-term prospective data are lacking.

METHODS

This was a prospective, community-based cohort study with 27-year follow-up (median follow-up 26.9 years; range 23.1 to 29.6 years). Participants from the Framingham Offspring Study (n = 1,323, enrolled between 1971 and 1975, mean age at enrollment 34 +/- 9 years; 52% women) underwent cardiac multidetector computed tomography assessment between 2002 and 2005. Associations between the long-term average of each cardiovascular risk factor and valve calcium were estimated using logistic regression.

RESULTS

Aortic valve calcium was present in 39% of participants and mitral valve calcium in 20%. In multivariable models, the odds ratio for aortic valve calcium associated with every SD increment in long-term mean total cholesterol was 1.74 (p < 0.0001); with every SD increment in high-density lipoprotein cholesterol, it was 0.77 (p = 0.002); and with every 9 cigarettes smoked per day, it was 1.23 (p = 0.002). Associations of similar magnitude were seen for mitral valve calcium. The mean of 3 serum C-reactive protein measurements was associated with mitral valve calcium (odds ratio: 1.29 per SD increment in C-reactive protein levels; p = 0.002). A higher Framingham risk score in early adulthood (40 years age or younger) was associated with increased prevalence and severity of aortic valve calcium measured 3 decades later.

CONCLUSIONS

Exposure to multiple atherosclerotic risk factors starting in early to mid-adulthood is associated with aortic and mitral valve calcium. Studies evaluating early risk factor modification to reduce the burden of valve disease are warranted.

Left-sided cardiac valvulitis in tristetraprolin-deficient mice: the role of tumor necrosis factor alpha

Inflammation may play a role in the etiology of both degenerative and rheumatic cardiac valve diseases. We report here that mice deficient in tristetraprolin (TTP), a protein with known anti-inflammatory functions, develop severe left-sided cardiac valvulitis. TTP is an mRNA binding protein that inhibits inflammation by destabilizing the mRNA encoding tumor necrosis factor alpha (TNF). This leads in turn to a TNF-excess syndrome characterized by systemic inflammation. Evaluation of hearts from TTP-/- mice demonstrated gross thickening of the mitral and aortic but not the tricuspid or pulmonary valves, accompanied by inflammatory cell infiltrates. To determine whether TNF played a role in the development of this valvulitis, we examined mice deficient in both TNF receptors and in TTP; four of five of these mice exhibited no histological evidence of valvulitis, but one mouse had aortic valve leaflet thickening with a cellular infiltrate. Four additional mice had no external evidence of valvular thickening. Cardiac valves of transgenic mice expressing human TNF developed mild aortic valve leaflet edema without evidence of hypercellularity. Thus, TTP deficiency in mice leads to left-sided cardiac valvulitis with prominent inflammatory cell involvement, due, at least in part, to excess TNF. These findings support the potential involvement of TNF and inflammation in the development of cardiac valve disease in man.

Association of aortic valve calcification to the presence, extent, and composition of coronary artery plaque burden: from the Rule Out Myocardial Infarction using Computer Assisted Tomography (ROMICAT) trial

BACKGROUND

Aortic valve calcification (AVC) is associated with cardiovascular risk factors and coronary artery calcification. We sought to determine whether AVC is associated with the presence and extent of overall plaque burden, as well as to plaque composition (calcified, mixed, and noncalcified).

METHODS

We examined 357 subjects (mean age 53 +/- 12 years, 61% male) who underwent contrast-enhanced electrocardiogram-gated 64-slice multidetector computed tomography from the ROMICAT trial for the assessment of presence and extent of coronary plaque burden according to the 17-coronary segment model and presence of AVC.

RESULTS

Patients with AVC (n = 37, 10%) were more likely than those without AVC (n = 320, 90%) to have coexisting presence of any coronary plaque (89% vs 46%, P < .001) and had a greater extent of coronary plaque burden (6.4 vs 1.8 segments, P < .001). Those with AVC had >3-fold increase odds of having any plaque (adjusted odds ratio [OR] 3.6, P = .047) and an increase of 2.5 segments of plaque (P < .001) as compared to those without AVC. When stratified by plaque composition, AVC was associated most with calcified plaque (OR 5.2, P = .004), then mixed plaque (OR 3.2, P = .02), but not with noncalcified plaque (P = .96).

CONCLUSION

Aortic valve calcification is associated with the presence and greater extent of coronary artery plaque burden and may be part of the later stages of the atherosclerosis process, as its relation is strongest with calcified plaque, less with mixed plaque, and nonsignificant with noncalcified plaque. If AVC is present, consideration for aggressive medical therapy may be warranted.

Aortic valve stenosis

Calcific aortic stenosis (AS) is primarily a disease of the elderly, possessing features that are biomechanical as well as systemic and inflammatory in nature, with risk factors and histopathology similar to atherosclerosis. To date no medical therapy has been shown to conclusively alter the progression of the disease, and for those with symptomatic AS, aortic valve replacement (AVR) is advocated. Factors that may alert the physician to an accelerated progression of calcific aortic valvular disease toward severe symptomatic AS include moderate aortic valve calcification, chronically dialyzed patients, and patients 80 years and older. There remains significant morbidity and mortality associated with AVR, and new techniques and technologies for AVR are being developed. For those who undergo successful AVR the long-term prognosis is good. A substantial number of patients with symptomatic AS present for anesthesia care for a variety of procedures. A thorough, modern understanding of AS and its course are necessary for the anesthesiologist to guide the patient through the perioperative period.

Relation of aortic valve and coronary artery calcium in patients with chronic kidney disease to the stage and etiology of the renal disease

Patients with chronic renal failure have increased cardiac calcium loads. Previous studies have investigated the prevalence and quantitative extent of aortic valve calcium (AVC) and coronary artery calcium (CAC) in patients with various stages of chronic kidney disease (CKD). However, the impact of preexisting atherosclerosis on the calcification burden has not been clarified. Therefore, this study was conducted to examine the effect of CKD stage as well as the primary cause of renal failure (atherosclerotic vs nonatherosclerotic) on AVC and CAC. Twenty-two, 13, and 28 patients with stage 3, 4, and 5 CKD, respectively, were included, of whom 24 had atherosclerotic CKD. Patients underwent electron-beam computed tomography to assess AVC and CAC. AVC was present in 27% of patients with stage 3 CKD, in 38% of patients with stage 4 CKD, and in 43% of patients with stage 5 CKD. CAC was present in 77% of patients with stage 3 CKD, in 54% of patients with stage 4 CKD, and in 64% of patients with stage 5 CKD. There was no correlation between CKD stage and the quantitative extent of AVC and CAC. AVC was more frequent (58% vs 23%, p <0.01) and more extensive (median score 43 [range 0 to 494] vs 0 [range 0 to 8], p <0.01) in patients with CKD caused by atherosclerotic renal disease than in patients with nonatherosclerotic causes of CKD. CAC was more frequent (83% vs 56%, p <0.05) and more extensive (median score 437 [range 61 to 1,565] vs 31 [range 0 to 155], p <0.001) in patients with atherosclerotic causes of CKD than in patients with CKD caused by nonatherosclerotic renal disease. In conclusion, the prevalence as well as the severity of AVC and CAC did not vary between patients with stage 3, 4, and 5 CKD. Cardiac calcification, both AVC and CAC, were more frequent and more severe in patients with atherosclerotic causes of renal failure. These results suggest that cardiac calcium is related to atherosclerotic burden rather than to the severity of CKD.

Impact of mitral annular calcification on cardiovascular events in a multiethnic community: the Northern Manhattan Study

OBJECTIVES

We sought to determine the magnitude of the association between mitral annular calcification (MAC) and vascular events in a multiethnic cohort.

BACKGROUND

Mitral annular calcification is common in the elderly and is associated with atherosclerotic risk factors. Its impact on the risk of cardiovascular events is controversial.

METHODS

The study cohort consisted of 1,955 subjects, ages >or=40 years, and free of prior myocardial infarction (MI) and ischemic stroke (IS). Mitral annular calcification was assessed by transthoracic 2-dimensional echocardiography. The association between MAC and MI, IS, and vascular death (VD) was examined by Cox proportional hazard models with adjustment for established cardiovascular risk factors. The effect of MAC thickness was also analyzed.

RESULTS

The mean age of the cohort was 68.0 +/- 9.7 years and the majority of subjects were Hispanics (56.8%). A total of 519 subjects (26.6%) had MAC. Of 498 patients with MAC thickness measurements available, 253 (13.1%) had mild to moderate MAC (1 to 4 mm) and 245 (12.7%) severe MAC (>4 mm). During a mean follow-up of 7.4 +/- 2.5 years, MI occurred in 100 (5.1%) subjects, IS in 104 (5.3%) subjects, and VD in 155 (8.0%) subjects. After adjustment for other cardiovascular risk factors, MAC was associated with an increased risk of MI (adjusted hazard ratio [HR]: 1.75; 95% confidence interval [CI]: 1.13 to 2.69, p = 0.011) and VD (adjusted HR: 1.53; 95% CI: 1.09 to 2.15, p = 0.015), but not IS (adjusted HR: 1.34; 95% CI: 0.87 to 2.05, p = 0.18). Further analysis revealed that the impact of MAC was related to its thickness, with MAC >4 mm being a strong and independent predictor of MI (adjusted HR: 1.89; 95% CI: 1.13 to 3.17, p = 0.008) and VD (adjusted HR: 1.81; 95% CI: 1.21 to 2.72, p = 0.002), and showing borderline association with IS (adjusted HR: 1.59; 95% CI: 0.95 to 2.67, p = 0.084).

CONCLUSIONS

In this multiethnic cohort, MAC was a strong and independent predictor of cardiovascular events, especially MI and VD. The risk increase was directly related to MAC severity.

Stentless valves treated by the L-hydro process in the aortic position in sheep

Calcification of glutaraldehyde-treated bioprosthetic heart valves is a major cause of long-term failure. We studied porcine aortic valves treated by the L-Hydro process and implanted into 14 juvenile sheep (group 1). Another 10 sheep were implanted with glutaraldehyde-treated porcine bioprostheses (group 2). The animals were sacrificed after 150 days and the explanted valves were analyzed for calcification. Hemodynamic measurements by echocardiography and angiography were carried out prior to sacrifice. Macroscopic analysis showed calcification and loss of mobility of the leaflets in all group 2 implants and in one group 1 implant. Light microscopy showed foci of calcification in all group 2 implants and in 3 valves from group 1. A significant reduction in the level of calcification was found in porcine bioprostheses treated by the L-Hydro process and implanted into the juvenile sheep model.

Vitamin K and vitamin D status: associations with inflammatory markers in the Framingham Offspring Study

In vitro data suggest protective roles for vitamins K and D in inflammation. To examine associations between vitamins K and D and inflammation in vivo, the authors used multiple linear regression analyses, adjusted for age, sex, body mass index, triglyceride concentrations, use of aspirin, use of lipid-lowering medication, season, menopausal status, and hormone replacement therapy. Participants were from the Framingham Offspring Study (1997-2001; n = 1,381; mean age = 59 years; 52% women). Vitamin K status, measured by plasma phylloquinone concentration and phylloquinone intake, was inversely associated with circulating inflammatory markers as a group and with several individual inflammatory biomarkers (p < 0.01). Percentage of undercarboxylated osteocalcin, a functional measure of vitamin K status, was not associated with overall inflammation but was associated with C-reactive protein (p < 0.01). Although plasma 25-hydroxyvitamin D was inversely associated with urinary isoprostane concentration, an indicator of oxidative stress (p < 0.01), overall associations between vitamin D status and inflammation were inconsistent. The observation that high vitamin K status was associated with lower concentrations of inflammatory markers suggests that a possible protective role for vitamin K in inflammation merits further investigation.

Epidemiology and genetics of calcific aortic valve disease

Calcific aortic valve disease is a common condition in the elderly and is associated with significant morbidity and mortality. Although biologically plausible roles in disease pathogenesis have been proposed for both lipoproteins and the renin-angiotensin system, no properly controlled, randomized trials have demonstrated that any pharmacologic therapy slows development of the disease. This review defines the stages of calcific aortic valve disease; discusses the role of nonechocardiographic techniques, such as cardiac computed tomography, that may allow identification and study of earlier-stage disease; reviews associated epidemiologic factors; and summarizes recent studies of "novel" risk factors, such as metabolic syndrome and inflammatory biomarkers. Finally, the role of genetics in this disease is receiving greater attention, and recent studies are reviewed that examine genetic polymorphisms and identify single-gene defects associated with this disease. Together these latter sets of studies emphasize that unique "nonatherosclerotic" factors can influence calcific aortic valve disease development, suggesting the possibility of novel therapeutic strategies for this condition.