Global burden of calcific aortic valve disease and attributable risk factors from 1990 to 2019

Dynamic Response of Heart Rate Variability to Active Standing in Aortic Valve Disease: Insights from Recurrence Quantification Analysis

INTRODUCTION

Aortic valve disease (AVD) is an inflammatory, lipid infiltration and calcification disease that has been associated with changes in the conventional linear heart rate variability (HRV) indices showing a marked shift towards sympathetic predominance and a deterioration of the autonomic control.

OBJECTIVE

To explore the HRV dynamics in AVD patients through nonlinear methods by recurrence quantification analysis (RQA).

METHODS

In total, 127 subjects participated in a cross-sectional study categorized into three groups: healthy valve (HV), aortic valve sclerosis (AVSc), and aortic valve stenosis (AVS), as determined by echocardiographic assessment. HRV data were collected from five-minute ECG recordings at both a supine position and active standing. RQA indices were calculated using the Cross Recurrence Plot Toolbox.

RESULTS

In the supine position, patients with AVS exhibited larger determinism and trapping time than those with AVSc and HV. The analysis of these differences revealed that determinism and laminarity increased progressively from HV to AVS. In the same way, the magnitude of change (Δ) between positions decreased and presented the lowest values in AVS in most of the nonlinear indices.

CONCLUSION

RQA indices of HRV in AVD patients indicate a rigidizing dynamic characterized by larger determinism and extended trapping times in fewer system states in relation to the severity of AVD. These findings establish a precedent for future perspective assessments for the implementation of these methods in medical software or devices.

2025 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association

BACKGROUND

The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2025 AHA Statistical Update is the product of a full year's worth of effort in 2024 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. This year's edition includes a continued focus on health equity across several key domains and enhanced global data that reflect improved methods and incorporation of ≈3000 new data sources since last year's Statistical Update.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Calcific aortic stenosis: omics-based target discovery and therapy development

Calcific aortic valve disease (CAVD) resulting in aortic stenosis (AS) is the most common form of valvular heart disease, affecting 2% of those over age 65. Those who develop symptomatic severe AS have an average further lifespan of <2 years without valve replacement, and three-quarters of these patients will develop heart failure, undergo valve replacement, or die within 5 years. There are no approved pharmaceutical therapies for AS, due primarily to a limited understanding of the molecular mechanisms that direct CAVD progression in the complex haemodynamic environment. Here, advances in efforts to understand the pathogenesis of CAVD and to identify putative drug targets derived from recent multi-omics studies [including (epi)genomics, transcriptomics, proteomics, and metabolomics] of blood and valvular tissues are reviewed. The recent explosion of single-cell omics-based studies in CAVD and the pathobiological and potential drug discovery insights gained from the application of omics to this disease area are a primary focus. Lastly, the translation of knowledge gained in valvular pathobiology into clinical therapies is addressed, with a particular emphasis on treatment regimens that consider sex-specific, renal, and lipid-mediated contributors to CAVD, and ongoing Phase I/II/III trials aimed at the prevention/treatment of AS are described.

Trymethylamine-N-oxide, a gut-derived metabolite, induces myofibroblastic activation of valvular interstitial cells through endoplasmic reticulum stress

Calcific aortic valve disease currently lacks effective treatments beyond surgical valve replacement, due to an incomplete understanding of its pathogenesis. Emerging evidence suggests that the gut microbiome influences cardiovascular health through the production of metabolites derived from dietary components. Among them, trimethylamine-N-oxide (TMAO) has been identified as a potential causal factor for several cardiovascular conditions. However, its role in the development of aortic valve disease remains poorly understood. This study sought to investigate the impact of TMAO on valvular interstitial cells (VICs), the most abundant cell type in the aortic valve. Here, we demonstrate that TMAO activates VICs towards a myofibroblastic profibrotic phenotype. Using an in vitro protocol to generate quiescent VICs, we found that TMAO induces the upregulation of myofibroblastic markers in a sex-independent manner. These quiescent VICs were more sensitive to TMAO than conventionally cultured VICs. Treatment with TMAO also elevated extracellular matrix production and oxidative stress, phenotypic hallmarks of an activated profibrotic state. Finally, inhibition of the endoplasmic reticulum stress kinase prior to TMAO treatment blocked all effects of this metabolite. These findings suggest that TMAO contributes to the early stages of valve disease by promoting VIC activation through endoplasmic reticulum stress mechanisms. Understanding the role of TMAO and other gut-derived metabolites in the pathogenesis of valve disease could inform the development of novel preventive or therapeutic strategies to modify or delay disease progression. Furthermore, these insights underscore the importance of host-microbiome interactions and highlight the potential for targeted dietary interventions to mitigate cardiovascular disease risk.

Global, Regional, and National Burden of Valvular Heart Disease, 1990 to 2021

BACKGROUND

Valvular heart disease poses an escalating global health challenge with an increasing impact on mortality and disability. This study aims to comprehensively analyze the global burden of valvular heart disease.

METHODS AND RESULTS

Using the Global Burden of Disease 2021 data, we analyzed the prevalence and disability-adjusted life years, examining implications across demographics and geographic regions. In 2021, an estimated 54.8 million (95% uncertainty interval [UI], 43.3-67.6) cases of rheumatic heart disease, 13.3 million (95% UI, 11.4-15.2) cases of nonrheumatic calcific aortic valve disease (CAVD), and 15.5 million (95% UI, 14.5-16.7) cases of nonrheumatic degenerative mitral valve disease (DMVD) were reported globally. Despite the rising prevalence, disability-adjusted life years declined between 1991 and 2021. Among individuals aged 70 years or older, the age-standardized prevalences were 1803.6 per 100 000 (95% UI, 1535.5-2055.7) for CAVD and 2148.9 per 100 000 (95% UI, 2001.4-2310.1) for DMVD. Sub-Saharan Africa had the highest age-standardized prevalence for rheumatic heart disease; Conversely, high-income regions led in CAVD and DMVD prevalence. Rheumatic heart disease had the highest age-standardized prevalence of 1184.2 per 100 000 (95% UI, 932.4-1478.2) in low Socio-Demographic Index (SDI) regions, whereas CAVD peaked at 349.8 per 100 000 (95% UI, 303.6-395.8) in high SDI regions. The most substantial increases in age-standardized prevalences of CAVD from 1990 to 2021 occurred in the middle SDI and low-middle SDI regions. A parallel trend was noted for DMVD.

CONCLUSIONS

Rheumatic heart disease remains a significant burden in low SDI regions, whereas CAVD and DMVD pose challenges in high SDI regions with aging populations.

Clinical profile, management strategy, and outcomes of patients with prosthetic valve thrombosis

Background: Prosthetic valve thrombosis (PVT) is a severe complication following prosthetic heart valve replacement, particularly in inadequately anticoagulated patients. Primary treatment options include intensive anticoagulation therapy, thrombolytic treatment (TT), and emergency surgery. This study aims to evaluate the clinical profile, management strategies, and short-term outcomes of patients with PVT. Methodology: Consecutive patients with PVT presenting to the emergency department of a tertiary care cardiac center were included in this study. Responses to treatment, hospital outcomes, and 30-day outcomes post-treatment were observed. Results: A total of 75 patients were analyzed, with a male predominance (50.7%) and a mean age of 39.5 ± 12.3 years. Bi-leaflet prosthetic valves were most common (96.0%), 54 (72.0%) had prosthetic mitral valve and 10 (13.3%) had prosthetic both mitral and aortic valves. Atrial fibrillation was present in 25.3% of cases. Treatment predominantly involved streptokinase (74.7%), followed by heparin (37.3%) and VKA (9.3%). Clinical success was achieved in 84.0% of cases, while 12.0% experienced clinical failure, including severe complications such as irreversible neurologic damage (1.3%) and bleeding (2.8%). The 30-day mortality rate was 12.0%, with recurring PVT and bleeding/embolic complications each in 1.5% of cases. Conclusion: Treatment of PVT with streptokinase, heparin, and VKA demonstrates efficacy, with a substantial proportion of patients achieving complete clinical success. However, the study highlights concerning outcomes, including clinical failure and severe complications. These findings underscore the importance of carefully balancing thrombolytic and anticoagulant therapies to mitigate potential adverse events.

Lipoprotein (a) and lipid-lowering treatment from the perspective of a cardiac surgeon. An impact on the prognosis in patients with aortic valve replacement and after heart transplantation

Lipoprotein(a) is a recognized risk factor for ASCVD. There is still no targeted therapy for Lp(a), however, drugs such as pelacarsen, olpasiran, zerlasiran, lepodisiran and muvalaplin are in clinical trials and have been shown to be effective in significantly reducing Lp(a) levels. Moreover, elevated Lp(a) levels significantly affect the prognosis of patients after aortic valve replacement (AVR) and heart transplantation (HTx). Therefore, the assessment of Lp(a) concentration in these patients will allow for a more accurate stratification of their cardiovascular risk, and the possibility of lowering Lp(a) will allow for the optimization of this risk. In this article, we summarized the most important information regarding the role of Lp(a) and lipid-lowering treatment in patients after AVR and HTx.

Aortic Valve Calcium Score: Applications in Clinical Practice and Scientific Research-A Narrative Review

In this narrative review, we investigate the essential role played by the computed tomography Aortic Valve Calcium Score (AVCS) in the cardiovascular diagnostic landscape, with a special focus on its implications for clinical practice and scientific research. Calcific aortic valve stenosis is the most prevalent type of aortic stenosis (AS) in industrialized countries, and due to the aging population, its prevalence is increasing. While transthoracic echocardiography (TTE) remains the gold standard, AVCS stands out as an essential complementary tool in evaluating patients with AS. The advantage of AVCS is its independence from flow; this allows for a more precise evaluation of patients with discordant findings in TTE. Further clinical applications of AVCS include in the assessment of patients before transcatheter aortic valve replacement (TAVR), as it helps in predicting outcomes and provides prognostic information post-TAVR. Additionally, we describe different AVCS thresholds regarding gender and the anatomical variations of the aortic valve. Finally, we discuss various scientific studies where AVCS was applied. As AVCS has some limitations, due to the pathophysiologies of AS extending beyond calcification and gender differences, scientists strive to validate contrast-enhanced AVCS. Furthermore, research on developing radiation-free methods of measuring calcium content is ongoing.

Investigating the Impact of a Gut metabolite on Valvular Interstitial Cell Activation

Calcified Aortic Valve Disease (CAVD) affects up to 13% of the U.S. population and is linked to diet-induced changes in metabolism. Recent studies suggest that the gut metabolite trimethyl amine oxide (TMAO) may be a biomarker for atherosclerosis. Given the shared risk factors between atherosclerosis and CAVD, we hypothesize that TMAO may contribute to CAVD by activating the primary cell type in the valve, valve interstitial cells (VIC). VICs are usually found in a quiescent phenotype in healthy valves; however, VICs isolated from porcine aortic valves exhibit spontaneous activation in traditional culture. Thus, to study VIC activation induced by exposure to TMAO, we first applied our lab-engineered protocol to generate quiescent VICs (qVICs). TMAO treatment led to qVIC activation, demonstrated by increased αSMA expression, proliferation, and angiogenic cytokine secretion after 3 days in culture. The response to TMAO was not sex-specific with both male and female VICs responding to treatment with this metabolite. These results demonstrate that TMAO, a gut microbiome-derived metabolite, promotes the activation of quiescent VICs toward a myofibroblastic phenotype in vitro, potentially contributing to the initiation of CAVD. Overall, these findings underscore the significance of host-microbe interactions in the progression of cardiovascular disease.

Identification of Circulating Inflammatory Proteins Associated with Calcific Aortic Valve Stenosis by Multiplex Analysis

Calcific aortic valve stenosis (CAVS) is characterized by increasing inflammation and progressive calcification in the aortic valve leaflets and is a major cause of death in the aging population. This study aimed to identify the inflammatory proteins involved in CAVS and provide potential therapeutic targets. We investigated the observational and causal associations of 92 inflammatory proteins, which were measured using affinity-based proteomic assays. Firstly, the case-control cohort identified differential proteins associated with the occurrence and progression of CAVS. Subsequently, we delved into exploring the causal impacts of these associated proteins through Mendelian randomization. This involved utilizing genetic instruments derived from cis-protein quantitative loci identified in genome-wide association studies, encompassing a cohort of over 400,000 individuals. Finally, we investigated the gene transcription and protein expression levels of inflammatory proteins by single-cell and immunohistochemistry analysis. Multivariate logistic regression and spearman's correlation analysis showed that five proteins showed a significant positive correlation with disease severity. Mendelian randomization showed that elevated levels of two proteins, namely, matrix metallopeptidase-1 (MMP1) and sirtuin 2 (SIRT2), were associated with an increased risk of CAVS. Immunohistochemistry and single-cell transcriptomes showed that expression levels of MMP1 and SIRT2 at the tissue and cell levels were significantly higher in calcified valves than in non-calcified control valves. These findings indicate that MMP1 and SIRT2 are causally related to CAVS and open up the possibility for identifying novel therapeutic targets.

Multimodal Analytical Tools to Enhance Mechanistic Understanding of Aortic Valve Calcification

This review focuses on technologies at the core of calcific aortic valve disease (CAVD) and drug target research advancement, including transcriptomics, proteomics, and molecular imaging. We examine how bulk RNA sequencing and single-cell RNA sequencing have engendered organismal genomes and transcriptomes, promoting the analysis of tissue gene expression profiles and cell subpopulations, respectively. We bring into focus how the field is also largely influenced by increasingly accessible proteome profiling techniques. In unison, global transcriptional and protein expression analyses allow for increased understanding of cellular behavior and pathogenic pathways under pathologic stimuli including stress, inflammation, low-density lipoprotein accumulation, increased calcium and phosphate levels, and vascular injury. We also look at how direct investigation of protein signatures paves the way for identification of targetable pathways for pharmacologic intervention. Here, we note that imaging techniques, once a clinical diagnostic tool for late-stage CAVD, have since been refined to address a clinical need to identify microcalcifications using positron emission tomography/computed tomography and even detect in vivo cellular events indicative of early stage CAVD and map the expression of identified proteins in animal models. Together, these techniques generate a holistic approach to CAVD investigation, with the potential to identify additional novel regulatory pathways.

2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association

BACKGROUND

The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2024 AHA Statistical Update is the product of a full year's worth of effort in 2023 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. The AHA strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional global data, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Alerting trends in epidemiology for calcific aortic valve disease, 1990-2019: An age-period-cohort analysis for the Global Burden of Disease Study 2019

AIMS

To assess the trends in calcific aortic valve disease (CAVD) epidemiology, with an emphasis on CAVD mortality, leading risk factors, and their associations with age, period, and birth cohort.

METHODS AND RESULTS

Prevalence, disability-adjusted life years, and mortality were derived from the Global Burden of Disease Study 2019. The age-period-cohort model was employed to study the detailed trends of CAVD mortality and its leading risk factors. Globally, CAVD showed unsatisfactory results from 1990 to 2019, with the CAVD deaths of 127 000 in 2019. CAVD mortality was substantially reduced in high socio-demographic index (SDI) countries [-1.45%, 95% confidence interval (CI) (-1.61 to -1.30)], mildly increased in high-middle SDI countries [0.22%, 95% CI (0.06-0.37)], and unchanged in other SDI quintiles. There was a noticeable transition in CAVD deaths from younger to older populations globally. The CAVD mortality increased exponentially with age, and the male had higher mortality than the female before 80 years old. Favourable period [0.69, 95% CI (0.66-0.72)] and birth effects [0.30, 95% CI (0.22-0.43)] were mainly observed in high SDI countries, while unfavourable effects were mostly noticed in high-middle SDI countries. High systolic blood pressure was the leading risk factor of CAVD deaths globally, and it showed favourable trends in high SDI regions.

CONCLUSION

Although CAVD mortality reduction was observed globally, unfavourable period, and cohort effects were found in many countries. Increase of mortality rate among the population ≥85 years was the common challenge across all SDI quintiles, stressing the necessity to further improve health care for CAVD patients worldwide.

The Impact of Left Ventricular Performance and Afterload on the Evaluation of Aortic Valve Stenosis: A 1D Mathematical Modeling Approach

The transaortic valvular pressure gradient (TPG) plays a central role in decision-making for patients suffering from severe aortic stenosis. However, the flow-dependence nature of the TPG makes the diagnosis of aortic stenosis challenging since the markers of cardiac performance and afterload present high physiological interdependence and thus, isolated effects cannot be measured directly in vivo. We used a validated 1D mathematical model of the cardiovascular system, coupled with a model of aortic stenosis, to assess and quantify the independent effect of the main left ventricular performance parameters (end-systolic (Ees) and end-diastolic (Eed) elastance) and principal afterload indices (total vascular resistance (TVR) and total arterial compliance (TAC)) on the TPG for different levels of aortic stenosis. In patients with critical aortic stenosis (aortic valve area (AVA) ≤ 0.6 cm2), a 10% increase of Eed from the baseline value was associated with the most important effect on the TPG (-5.6 ± 0.5 mmHg, p < 0.001), followed by a similar increase of Ees (3.4 ± 0.1 mmHg, p < 0.001), in TAC (1.3 ±0.2 mmHg, p < 0.001) and TVR (-0.7 ± 0.04 mmHg, p < 0.001). The interdependence of the TPG left ventricular performance and afterload indices become stronger with increased aortic stenosis severity. Disregarding their effects may lead to an underestimation of stenosis severity and a potential delay in therapeutic intervention. Therefore, a comprehensive evaluation of left ventricular function and afterload should be performed, especially in cases of diagnostic challenge, since it may offer the pathophysiological mechanism that explains the mismatch between aortic severity and the TPG.