Exercise electrocardiography test in patients with aortic stenosis. Differential features from that of coronary artery disease

Bench to bedside defining calcific aortic valve disease: osteocardiology

INTRODUCTION

For years, calcific aortic valve disease (CAVD) was thought to be due to a degenerative process, but recent scientific discoveries have proven it to be an active process. Understanding the cellular mechanisms for the development of disease and translating the cellular changes critical in the development of calcific phenotypes. The use of multimodality imaging has been the gold standard to define the development of calcification to determine the timing of therapy.

AREAS COVERED

This review will discuss the scientific literature in a new and evolving field known as osteocardiology, which specifically defines the cellular mechanisms involved in the development of the osteogenic phenotype in the heart and vasculature. The work in this field has been highlighted by the calcific aortic valve disease working group at the NIH. This review will discuss the appropriate use criteria for multimodality imaging techniques to identify early cellular and hemodynamic disease progression in the aortic valve to help determine the timing of therapy, the osteocardiology theory.

EXPERT OPINION

The authors will provide their background in basic science and clinical medicine to support the opinions in this paper.

Association between carotid and coronary artery disease in patients with aortic valve stenosis: an angiographic study

BACKGROUND

Patients with aortic stenosis have a high prevalence of coronary artery disease, but there is little information about the association of coronary artery disease and carotid artery disease.

METHODS

The study includes 317 consecutive patients with aortic stenosis, who underwent carotid and coronary angiography during the same catheterization before aortic valve replacement.

RESULTS

At univariate analysis, the prevalence of coronary artery disease was associated with (1) presence of carotid artery disease (P < .001); (2) angina pectoris as presentation symptom (P < .001); (3) age more than 65 years (P < .05); and (4) hypertension (P < .05). At multivariate analysis, only carotid artery disease, angina, and age emerged as independent predictors of coronary artery disease. The combination of 2 variables (carotid artery disease, angina) allowed the identification of 4 groups, with decreasing prevalence of coronary artery disease: (1) angina+/carotid artery disease+: 85%; (2) angina-/ carotid artery disease+: 50%; (3) angina+/carotid artery disease-: 41%; (4) angina-/carotid artery disease-: 21% (P < .001).

CONCLUSION

In patients with symptomatic aortic stenosis, the presence of significant carotid artery disease is a strong marker of significant coronary artery disease.

[Comparative study of exercise-induced ischaemia in coronaropathy and aortic stenosis]

OBJECTIVE

To compare exercise and recovery data between a population of patients with proven CAD and patients with pure aortic stenosis (AS).

PATIENTS AND METHODS

Exercise testing results (bicycle ergometry) of 45 patients with AS (34 men, 66+/-12 years, 56+/-20 mmHg peak-to-peak gradient and valve area 0.78+/-0.48cm2) were compared to exercise testing results of 50 patients with CAD (41 men, 65+/-9 years, greater or equal to 70% stenosis on one vessel in 62%, two vessels in 30%, three vessels in 8%).

RESULTS

During exercise, 38% patients with AS and 82% patients with CAD had clinical symptoms. In the AS group, exercise duration was longer, heart rate (HR) was higher, maximal systolic and diastolic blood pressure were lower than in CAD group. The increase of systolic blood pressure was lower in the AS group (34+/-21 mmHg versus 47+/-27 mmHg, p<0.02). Maximal load achieved was not significantly different. Exercise ST depression appeared in 76% of AS group and 88% of CAD group (NS). No difference was found in ST depression, Detrano index and ST segment/HR slope. During recovery, no difference was found in HR variations. Clockwise rotation of the ST/HR recovery loop was more frequent in CAD group (35 patients versus 19 patients, p<0.001).

CONCLUSION

Most of the exercise and recovery data are similar in patients with AS and CAD. Significant discriminating criteria were the increase of systolic blood pressure during exercise and ST/HR recovery loop.

Exercise Testing in Aortic Stenosis

Physician-supervised exercise testing in asymptomatic patients with aortic stenosis allows an objective assessment of the hemodynamic response to exercise and it provides a measure of exercise capacity. Exercise testing cannot be used to determine the presence or absence of coronary artery disease, but limited data indicate that exercise testing can provide prognostic information. The results of such testing can be used to provide an exercise prescription and to reassure the patient who might otherwise excessively limit his or her activity.