Temporal changes in aortic valve replacement according to age in Denmark: nationwide data from 2008 to 2020

Background

Since the introduction of transcatheter aortic valve implantation (TAVI), the management of symptomatic severe aortic stenosis has changed. Recent published European guidelines (2021) favours TAVI over surgical aortic valve replacements (SAVR) in patients with older age (≥75 years of age) or patients with high surgical risk. The study of nationwide practice patterns for AVR is important and renders the possibility to evaluate whether clinical practice differs from current guidelines.

Purpose

To evaluate temporal changes in use of isolated aortic valve replacement (AVR) procedures according to age in the era of TAVI in Denmark.

Methods

We identified all first-time aortic valve replacement procedures (TAVI or SAVR) from 2008 until the end of 2020 through administrative registries in Denmark. Patients with no prior diagnosis of aortic stenosis at time of AVR were excluded. Patients with prior AVR or valve repair were excluded. SAVR was divided according to type of prostheses: surgical bioprostheses and mechanical prostheses. To evaluate changes according to age the study cohort was divided into two age groups: <75 and ≥75 years of age.

Results

Between 2008 and 2020, 12,313 first-time isolated AVR procedures were performed in Denmark. Volume of isolated AVR increased from 621 to 1256 procedures per year (ptrend <0.001). Isolated SAVR was performed in 6,548 patients (53.2%) and TAVI in 5,765 patients (46.8%). Median age of TAVI patients was 81.4 [76.9–85.2] years of age compared to 73.1 [68.0-≥77.7] in patients receiving surgical bioprostheses and TAVI patients had a higher degree of comorbidity (TAVI: 70% of patients with Charlson comorbidity score ≥1, surgical bioprostheses: 50% of patients with Charlson comorbidty score ≥1). TAVI increased during study period compared to isolated SAVR, where a decreasing trend was observed from 2014 and onwards. In <75-year-old patients, volume of TAVI significantly increased during study period (ptrend<0.001), whereas volume of surgical bioprostheses remained stable. Volume of mechanical prostheses decreased over time (ptrend <0.001) TAVI increased in ≥75-year-old patients (ptrend <0.001) and TAVI accounted for 91.5% of all isolated AVR procedures in 2020. In contrast, volume of isolated SAVR declined driven by a decreasing use of surgical bioprostheses (ptrend=0.001). (Figure 1).

Conclusions

Volume of isolated aortic valve replacement (AVR) doubled from 2008 and 2020. The increase in isolated AVR was driven by transcatheter aortic valve implantation (TAVI). TAVI has become the predominant choice of isolated AVR in management of aortic stenosis and our results suggest that real-world practise patterns are in line with current guideline recommendations.

Funding Acknowledgement

Type of funding sources: None.

Temporal sequence of atrial fibrillation and chronic obstructive pulmonary disease diagnosis is associated with mortality risk

Background

Chronic obstructive pulmonary disease (COPD) is concomitantly present in 13% of atrial fibrillation (AF) patients and negatively impacts prognosis in AF patients (1). Nevertheless, the temporal sequence and time between diagnosis of each disease may vary between individuals (2).

Purpose

To describe whether the temporal sequence of diagnosis of AF and COPD is associated with mortality in patients with both AF and COPD diagnosed.

Methods

This nationwide study assessed all patients between 18 to 85 years diagnosed with both COPD and AF between 1999 and 2018 in Denmark. Follow up started at the time of the second diagnosis. Three groups were defined according to the temporal sequence of diagnosis: COPD diagnosed at least 1 year before AF (COPD-First), AF diagnosed at least 1 year before COPD (AF-First) and COPD and AF diagnosed within a one-year time frame (AF∼COPD).

Results

Among 62,806 patients analyzed (75.0 [69.0–79.7] years; 56.5% males; mean follow-up 2.2 years) 27,809 (44.3%) were in the COPD-First group, 19,556 (31.1%) in the AF-First group and 15,441 (24.5%) in the AF∼COPD group. While age was similar across groups, the sex distribution differed, with the lowest proportion of males (53.1%) in the COPD-First group and the highest (61.2%) proportion of males in the AF-First group. Moreover, cardiovascular risk factors and diseases were more frequent in the AF-First group and the lowest in the COPD-First group.

After 5 years of follow up, 31,494 (58.6%) died. Males died more frequently than females (59.4% vs. 57.4%). Mortality was higher in the COPD-First group (61.8% for COPD-First, 55.1% for AF-First and 57.2% for AF∼COPD, Figure 1) and the causes of death were different among the 3 groups (38.8%, 24.1%, 27.0% for pulmonary cause and 26.1%, 32.8% and 36.6% for cardiac cause in the COPD-First, AF first and AF∼COPD respectively).

In a multivariable Cox-regression model adjusted for age, sex, type 2 diabetes, history of acute myocardial infarction, cancer, chronic kidney disease, stroke, AF∼COPD group (HR 1.14, 95% CI 1.11–1.17; P<0.0001) and COPD-First group (HR 1.26, 95% CI 1.23–1.29; P<0.0001) had a higher risk of death as compared to the AF-First group. Using time between diagnoses in a restricted cubic spline and adjusting for potential cofounders a COPD diagnosis preceding an AF diagnosis was associated with a higher risk of death than an AF diagnosis preceding a COPD diagnosis (Figure 2).

Conclusion

In patients with AF and COPD, the temporal sequence of diagnosis impacts prognosis, independently of other comorbidities. A concomitant diagnosis of AF in patients with already previously diagnosed COPD is associated with the worst prognosis.

Funding Acknowledgement

Type of funding sources: None.

Income and education are associated with incidence of sudden cardiac death in a general population cohort

Funding Acknowledgements

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Union’s Horizon 2020 research and innovation programme under acronym ESCAPE-NET, registered under grant agreement No 733381

Introduction

Socioeconomic status is associated to all-cause mortality and common cardiac risk factors. The association between socioeconomic status and sudden cardiac death (SCD) taking prevalence of other risk factors into account has not been fully established.

Objective

The aim of this study was to investigate the association between income and education level and incidence of SCD.

Methods

All participants in the third wave of the Copenhagen City Heart Study were followed from 1993 to 2016 and all deaths were adjudicated using high quality death certificates, autopsy reports, and national registry data. Medical history and social demographics were self-reported. Hazard ratios (HR) were calculated using Cox proportional hazards regression and adjusted cumulative incidences were predicted using cause specific cox models.

Results

The study enrolled 10099 participants who were alive at start of follow up (median age at entry (IQR): 61 (48-72) years, 56% female). During 24 years of follow up, there were 5575 deaths of which 834 were classified as SCD. Compared with lowest income group and adjusted for age, sex, job, and education, higher income was associated with lower HR of SCD: middle income HR 0.82 (95% CI: 0.69-0.98) and high income HR 0.62 (0.47-0.81). This effect was attenuated, but still present, when adjusting for common cardiac risk factors (smoking, alcohol, BMI, physical activity, AMI, diabetes, hypertension, hypercholesterolemia). Compared with no education, increasing length of education was associated with lower HR of SCD: apprenticeship HR 0.82 (0.68-0.98), short education HR 0.80 (0.67-0.96), bachelor’s degree HR 0.56 (0.41-0.76), master’s degree HR 0.41 (0.28-0.59). This effect was also attenuated when adjusting for risk factors, job, and income. Adjusted cumulative incidences of SCD during the first 10 years of follow up according to income and education are shown in the figures.

Conclusions

In this study we found an association between lower income and shorter education and increased risk of SCD, an association not fully explained by prevalence of common cardiac risk factors, calling for further research into competing causes of SCD.

Clinical risk factors associated with ventricular fibrillation during first ST-elevation myocardial infarction

Funding Acknowledgements

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Union’s Horizon 2020 research and innovation programme under acronym ESCAPE-NET, registered under grant agreement No 733381

Introduction

Sudden cardiac death (SCD) remains a major public health issue. Most cases in the general population are caused by ischemic heart disease, and often occur in patients without known ischemic heart disease. The assessment of risk factors may point to novel causal pathways or new targets for intervention and risk prediction of SCD.

Objective

The aim of this study was to evaluate the effect of family history of sudden death, prior history of atrial fibrillation (AF), and anterior infarct location on ECG on the development of ventricular fibrillation (VF) during first ST-elevation myocardial infarction (STEMI).

Methods

We performed individual participant data meta-analyses of three European case-control studies including first STEMI patients (aged 18-80 years) with VF (cases) and without VF (controls) before revascularization (GEVAMI, AGNES, and PREDESTINATION). Analyses were done using fixed-effect, inverse variance weighted meta-analysis and multivariable logistic regression. Potential confounding variables were identified using causal diagrams and missing data were handled with multiple imputation for each cohort separately.

Results

We included 1664 cases and 2497 controls (median age (IQR) = 59 (51-67) years, 20% females) in the analyses. After adjusting for potential confounding, we found an independent and additive association between the three exposures and VF (see picture): for family history of sudden death odds ratio (OR) 1.59 (95% confidence interval: 1.37-1.85), for AF OR 2.41 (1.49-3.89), and for anterior myocardial infarction OR 1.50 (1.32-1.71). Further investigation indicated increased effect of family history with multiple sudden deaths in the family, a stronger effect of AF on VF developing within the first minutes of symptoms, and the effect of anterior infarctions being modified by enzymatically determined infarct size. The three risk factors showed an additive effect: with one factor present OR 1.59 (1.38-1.84), two factors OR 2.41 (1.95-2.99), and all three factors OR 5.49 (1.43-21.1). Complete case analysis gave similar results for all analyses.

Conclusions

Family history of sudden death, history of AF, and anterior infarct location with significant interaction with enzymatic infarct size were all independently and additively associated with an increased risk of VF in patients with a first STEMI.

4309Structural or functional left sided heart disease found on echocardiographic screening is associated with a higher risk of death in patients with end stage renal disease receiving haemodialysis

Introduction

Cardiovascular disease is the leading cause of death in patients with end-stage renal disease on haemodialysis. Guidelines recommend echocardiography in all incident patients on dialysis and every three years, or when considered for kidney transplantation. The prognostic value of significant valve disease or reduced systolic function detected by echocardiographic screening is however not clear.

Purpose

We aimed to test the hypothesis that structural heart disease in an unselected, contemporary population of patients on maintenance dialysis is associated to a higher risk of death.

Methods

Adult chronic haemodialysis patients in two large dialysis centers had transthoracic echocardiography performed immediately prior to dialysis and were followed prospectively. Significant structural or functional left sided heart disease was defined as moderate or severe left-sided valve disease or left ventricular ejection fraction (LVEF) ≤40%.

Results

Among the 247 included patients (66 [IQR 64–67] years of age, 68% male), 54 (22%) had significant structural or functional left sided heart disease. An LVEF ≤40% was observed in 31 patients (13%). Severe or moderate aortic stenosis was present in 4 (2%) and 16 (7%) patients respectively, moderate mitral regurgitation in 4 (2%) patients and mitral stenosis in one (0.4%) patient. In more than half of the patients (56%), significant structural or functional left sided heart disease was not recognized prior to the study. After 2.8 years of follow-up, all-cause mortality was 52% for patients with significant heart disease and 32% for patients without significant structural heart disease (hazard ratio [HR] 1.95 (95% CI 1.25–3.06) (Figure). On multivariable adjusted Cox proportional hazard analysis, including age, sex, ischemic heart disease, diabetes, hypertension and time on dialysis, structural heart disease was an independent predictor of mortality with a HR of 1.60 (95% CI 1.01–2.55) along with age (HR per year 1.05 [95% CI 1.03–1.07]).

Kaplan-Meier estimate of survival

Conclusion

Left ventricular systolic dysfunction and moderate to severe valve disease are common and often unrecognized in patients with end-stage renal failure on haemodialysis and are associated with a higher risk of death.