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Tsampasian V, Grafton-Clarke C, Gracia Ramos AE, Asimakopoulos G, Garg P, Prasad S, Ring L, McCann GP, Rudd J, Dweck MR, Vassiliou VS. Management of asymptomatic severe aortic stenosis: a systematic review and meta-analysis. Open Heart 2022; 9:e001982. [PMID: 35581008 PMCID: PMC9109115 DOI: 10.1136/openhrt-2022-001982] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 04/05/2022] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES The management of severe aortic stenosis mandates consideration of aortic valve intervention for symptomatic patients. However, for asymptomatic patients with severe aortic stenosis, recent randomised trials supported earlier intervention. We conducted a systematic review and meta-analysis to evaluate all the available data comparing the two management strategies. METHODS PubMed, Cochrane and Web of Science databases were systematically searched from inception until 10 January 2022. The search key terms were 'asymptomatic', 'severe aortic stenosis' and 'intervention'. RESULTS Meta-analysis of two published randomised trials, AVATAR and RECOVERY, included 302 patients and showed that early intervention resulted in 55% reduction in all-cause mortality (HR=0.45, 95% CI 0.24 to 0.86; I2 0%) and 79% reduction in risk of hospitalisation for heart failure (HR=0.21, 95% CI 0.05 to 0.96; I2 15%). There was no difference in risk of cardiovascular death between the two groups (HR=0.36, 95% CI 0.03 to 3.78; I2 78%). Additionally, meta-analysis of eight observational studies showed improved mortality in patients treated with early intervention (HR=0.38, 95% CI 0.26 to 0.56; I2 77%). CONCLUSION This meta-analysis provides evidence that, in patients with severe asymptomatic aortic stenosis, early intervention reduces all-cause mortality and improves outcomes compared with conservative management. While this is very encouraging, further randomised controlled studies are needed to draw firm conclusions and identify the optimal timing of intervention. PROSPERO REGISTRATION NUMBER CRD42022301037.
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Affiliation(s)
- Vasiliki Tsampasian
- Cardiology, Norfolk and Norwich University Hospital, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Ciaran Grafton-Clarke
- Cardiology, Norfolk and Norwich University Hospital, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Abraham Edgar Gracia Ramos
- Departamento de Medicina Interna, Centro Medico Nacional "La Raza", IMSS, Ciudad de Mexico, Mexico
- Seccion de Estudios de Posgrado e Investigacion, Escuela Superior de Medicina, Instituto Politecnico Nacional, Mexico City, Mexico
| | - George Asimakopoulos
- Cardiology, Royal Brompton and Harefield NHS Trust, London, UK
- School of Medicine, Imperial College London, London, UK
| | - Pankaj Garg
- Cardiology, Norfolk and Norwich University Hospital, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Sanjay Prasad
- Cardiology, Royal Brompton and Harefield NHS Trust, London, UK
- School of Medicine, Imperial College London, London, UK
| | - Liam Ring
- Cardiology, West Suffolk Hospital NHS Trust, Bury Saint Edmunds, UK
| | - Gerry P McCann
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- Leicester NIHR Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - James Rudd
- Division of Cardiovascular Medicine, University of Cambridge, Cambridge, UK
| | - Marc R Dweck
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Vassilios S Vassiliou
- Cardiology, Norfolk and Norwich University Hospital, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
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Abstract
PURPOSE OF REVIEW Degenerative aortic stenosis (AS) is one of the most prevalent heart valve diseases in the adult population. The understanding of AS pathophysiology and involved risk factors have recently undergone a great advance, with low-density lipoprotein cholesterol (LDL-C), lipoprotein (a) [Lp(a)] and other clinical conditions taking on a relevant role. Although little is known about the prevention of AS, we can progressively find more evidence of the possible use of drugs to control risk factors as tools that may delay the progression to severe AS and aortic valve replacement. RECENT FINDINGS Several factors have shown to be solid predictors of the development of AS. Mendelian randomization and observational studies on risk factors specifically lipid factors, such as hypercholesterolemia, Lp(a), proprotein convertase subtilisin/kexin type 9 and hypertension have provided meaningful new information. The SAFEHEART study has significantly contributed to define the role of LDL-C and Lp(a) in AS. SUMMARY In this review we discuss the interrelationship of dyslipidemia, especially hypercholesterolemia and Lp(a) in the development and prognosis of valvular AS. New imaging tools may contribute to its early detection. Future studies with proprotein convertase subtilisin/kexin type 9 inhibitors and specific therapies to lower Lp(a) might contribute to delay AS development.
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Affiliation(s)
- Pedro Mata
- Fundación Hipercolesterolemia Familiar, Madrid, Spain
| | - Rodrigo Alonso
- Fundación Hipercolesterolemia Familiar, Madrid, Spain
- Center for Advanced Metabolic Medicine and Nutrition, Santiago, Chile
| | - Leopoldo Pérez de Isla
- Fundación Hipercolesterolemia Familiar, Madrid, Spain
- Cardiology Department, Hospital Clínico San Carlos, IDISSC, Facultad de Medicina, Universidad Complutense, Madrid
| | - Lina Badimón
- Fundación Hipercolesterolemia Familiar, Madrid, Spain
- Cardiovascular Program - ICCC, Institut de Recerca del Hospital Santa Creu i Sant Pau, IIB Sant Pau, Ciber CV, Barcelona, Spain
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Otto CM. Heartbeat: public involvement in cardiovascular research. Heart 2021; 107:771-773. [PMID: 33893214 DOI: 10.1136/heartjnl-2021-319452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Catherine M Otto
- Division of Cardiology, University of Washington, Seattle, Washington, USA
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