RESUMO
BACKGROUND: Aortic valve calcification (AVC) indexation to the aortic annulus (AA) area measured by Doppler echocardiography (AVCdEcho) provides powerful prognostic information in patients with aortic stenosis (AS). However, the indexation by AA measured by multidetector computed tomography (AVCdCT) has never been evaluated. The aim of this study was to compare AVC, AVCdCT, and AVCdEcho with regard to hemodynamic correlations and clinical outcomes in patients with AS. METHODS: Data from 889 patients, mainly White, with calcific AS who underwent Doppler echocardiography and multidetector computed tomography within the same episode of care were retrospectively analyzed. AA was measured both by Doppler echocardiography and multidetector computed tomography. AVCdCT severity thresholds were established using receiver operating characteristic curve analyses in men and women separately. The primary end point was the occurrence of all-cause mortality. RESULTS: Correlations between gradient/velocity and AVCd were stronger (both P≤0.005) using AVCdCT (r=0.68, P<0.001 and r=0.66, P<0.001) than AVC (r=0.61, P<0.001 and r=0.60, P<0.001) or AVCdEcho (r=0.61, P<0.001 and r=0.59, P<0.001). AVCdCT thresholds for the identification of severe AS were 334 Agatston units (AU)/cm2 for women and 467 AU/cm2 for men. On a median follow-up of 6.62 (6.19-9.69) years, AVCdCT ratio was superior to AVC ratio and AVCdEcho ratio to predict all-cause mortality in multivariate analyses (hazard ratio [HR], 1.59 [95% CI, 1.26-2.00]; P<0.001 versus HR, 1.53 [95% CI, 1.11-1.65]; P=0.003 versus HR, 1.27 [95% CI, 1.11-1.46]; P<0.001; all likelihood test P≤0.004). AVCdCT ratio was superior to AVC ratio and AVCdEcho ratio to predict survival under medical treatment in multivariate analyses (HR, 1.80 [95% CI, 1.27-1.58]; P<0.001 compared with HR, 1.55 [95% CI, 1.13-2.10]; P=0.007; HR, 1.28 [95% CI, 1.03-1.57]; P=0.01; all likelihood test P<0.03). AVCdCT ratio predicts mortality in all subgroups of patients with AS. CONCLUSIONS: AVCdCT appears to be equivalent or superior to AVC and AVCdEcho to assess AS severity and predict all-cause mortality. Thus, it should be used to evaluate AS severity in patients with nonconclusive echocardiographic evaluations with or without low-flow status. AVCdCT thresholds of 300 AU/cm2 for women and 500 AU/cm2 for men seem to be appropriate to identify severe AS. Further studies are needed to validate these thresholds, especially in diverse populations.
Assuntos
Estenose da Valva Aórtica , Valva Aórtica , Calcinose , Ecocardiografia Doppler , Tomografia Computadorizada Multidetectores , Valor Preditivo dos Testes , Índice de Gravidade de Doença , Humanos , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/fisiopatologia , Estenose da Valva Aórtica/mortalidade , Masculino , Feminino , Tomografia Computadorizada Multidetectores/métodos , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/fisiopatologia , Valva Aórtica/patologia , Estudos Retrospectivos , Idoso , Calcinose/diagnóstico por imagem , Calcinose/fisiopatologia , Calcinose/mortalidade , Ecocardiografia Doppler/métodos , Idoso de 80 Anos ou mais , Prognóstico , Curva ROC , Hemodinâmica , Pessoa de Meia-Idade , Fatores de RiscoRESUMO
INTRODUCTION: In chronic obstructive pulmonary disease (COPD), chest computed tomography (CT) provides clinically important cardiovascular findings, which include diameter of pulmonary artery (PA), its ratio to the diameter of the aorta (PA:A ratio), and coronary artery calcium score (CACS). The clinical importance of these cardiovascular findings has not been fully assessed in Japan, where cardiovascular morbidity and/or mortality is reported to be much less compared with Western counterparts. METHODS: PA diameter and PA:A ratio were measured in 172 and 130 patients with COPD who enrolled in the Hokkaido COPD cohort study and the Kyoto University cohort, respectively. CACS was measured in 131 and 128 patients in each cohort. RESULTS: While the highest quartile group in PA diameter was associated with higher all-cause mortality compared to the lowest quartile group in both cohorts, individual assessments of PA:A ratio and CACS were not associated with the long-term clinical outcomes. When PA diameter and CACS were combined, patients with PA enlargement (diameter >29.5 mm) and/or coronary calcification (score >440.8) were associated with higher all-cause mortality in both cohorts. CONCLUSION: Combined assessment of PA enlargement and CACS was associated with poor prognosis, which provides a clinical advantage in management of patients with COPD even in geographical regions with lower risk of cardiovascular diseases.
Assuntos
Calcinose/diagnóstico por imagem , Calcinose/patologia , Vasos Coronários/diagnóstico por imagem , Vasos Coronários/patologia , Artéria Pulmonar/diagnóstico por imagem , Artéria Pulmonar/patologia , Doença Pulmonar Obstrutiva Crônica/diagnóstico por imagem , Doença Pulmonar Obstrutiva Crônica/patologia , Idoso , Calcinose/mortalidade , Estudos de Coortes , Feminino , Fatores de Risco de Doenças Cardíacas , Humanos , Hipertrofia/diagnóstico por imagem , Hipertrofia/mortalidade , Hipertrofia/patologia , Japão/epidemiologia , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Doença Pulmonar Obstrutiva Crônica/mortalidadeRESUMO
BACKGROUND: Nonrheumatic valvular diseases are common; however, no studies have estimated their global or national burden. As part of the Global Burden of Disease Study 2017, mortality, prevalence, and disability-adjusted life-years (DALYs) for calcific aortic valve disease (CAVD), degenerative mitral valve disease, and other nonrheumatic valvular diseases were estimated for 195 countries and territories from 1990 to 2017. METHODS: Vital registration data, epidemiologic survey data, and administrative hospital data were used to estimate disease burden using the Global Burden of Disease Study modeling framework, which ensures comparability across locations. Geospatial statistical methods were used to estimate disease for all countries, because data on nonrheumatic valvular diseases are extremely limited for some regions of the world, such as Sub-Saharan Africa and South Asia. Results accounted for estimated level of disease severity as well as the estimated availability of valve repair or replacement procedures. DALYs and other measures of health-related burden were generated for both sexes and each 5-year age group, location, and year from 1990 to 2017. RESULTS: Globally, CAVD and degenerative mitral valve disease caused 102 700 (95% uncertainty interval [UI], 82 700-107 900) and 35 700 (95% UI, 30 500-42 500) deaths, and 12.6 million (95% UI, 11.4 million-13.8 million) and 18.1 million (95% UI, 17.6 million-18.6 million) prevalent cases existed in 2017, respectively. A total of 2.5 million (95% UI, 2.3 million-2.8 million) DALYs were estimated as caused by nonrheumatic valvular diseases globally, representing 0.10% (95% UI, 0.09%-0.11%) of total lost health from all diseases in 2017. The number of DALYs increased for CAVD and degenerative mitral valve disease between 1990 and 2017 by 101% (95% UI, 79%-117%) and 35% (95% UI, 23%-47%), respectively. There is significant geographic variation in the prevalence, mortality rate, and overall burden of these diseases, with highest age-standardized DALY rates of CAVD estimated for high-income countries. CONCLUSIONS: These global and national estimates demonstrate that CAVD and degenerative mitral valve disease are important causes of disease burden among older adults. Efforts to clarify modifiable risk factors and improve access to valve interventions are necessary if progress is to be made toward reducing, and eventually eliminating, the burden of these highly treatable diseases.
Assuntos
Insuficiência da Valva Aórtica/epidemiologia , Estenose da Valva Aórtica/epidemiologia , Valva Aórtica/patologia , Calcinose/epidemiologia , Saúde Global , Insuficiência da Valva Mitral/epidemiologia , Prolapso da Valva Mitral/epidemiologia , Distribuição por Idade , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/cirurgia , Insuficiência da Valva Aórtica/diagnóstico por imagem , Insuficiência da Valva Aórtica/mortalidade , Insuficiência da Valva Aórtica/cirurgia , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/mortalidade , Estenose da Valva Aórtica/cirurgia , Calcinose/diagnóstico por imagem , Calcinose/mortalidade , Calcinose/cirurgia , Efeitos Psicossociais da Doença , Feminino , Disparidades nos Níveis de Saúde , Disparidades em Assistência à Saúde , Humanos , Masculino , Insuficiência da Valva Mitral/diagnóstico por imagem , Insuficiência da Valva Mitral/mortalidade , Insuficiência da Valva Mitral/cirurgia , Prolapso da Valva Mitral/diagnóstico por imagem , Prolapso da Valva Mitral/mortalidade , Prolapso da Valva Mitral/cirurgia , Prevalência , Qualidade de Vida , Medição de Risco , Fatores de Risco , Fatores de TempoRESUMO
Background Prospectively collected frailty markers are associated with an incremental 1-year mortality risk after transcatheter aortic valve replacement (TAVR) compared with comorbidities alone. Whether information on frailty markers captured retrospectively in administrative billing data is similarly predictive of long-term mortality after TAVR is unknown. We sought to characterize the prognostic importance of frailty factors as identified in healthcare billing records in comparison to validated measures of frailty for the prediction of long-term mortality after TAVR. Methods and Results Adult patients undergoing TAVR between August 25, 2011, and September 29, 2015, were identified among Medicare fee-for-service beneficiaries. The Johns Hopkins Claims-based Frailty Indicator was used to identify frail patients. We used nested Cox regression models to identify claims-based predictors of mortality up to 4 years post-procedure. Four groups of variables, including cardiac risk factors, noncardiac risk factors, patient procedural risk factors, and nontraditional markers of frailty, were introduced sequentially, and their integrated discrimination improvement was assessed. A total of 52 338 TAVR patients from 558 clinical sites were identified, with a mean follow-up time period of 16 months. In total, 14 174 (27.1%) patients died within the study period. The mortality rate was 53.9% at 4 years post-TAVR. A total of 34 863 (66.6%) patients were defined as frail. The discrimination of each of the 4 models was 0.60 (95% CI, 0.59-60), 0.65 (95% CI, 0.64-0.65), 0.68 (95% CI, 0.67-0.68), and 0.70 (95% CI, 0.69-0.70), respectively. The addition of nontraditional frailty markers as identified in claims improved mortality prediction above and beyond traditional risk factors (integrated discrimination improvement: 0.019; P<0.001). Conclusions Risk prediction models that include frailty as identified in claims data can be used to predict long-term mortality risk after TAVR. Linkage to claims data may allow enhanced mortality risk prediction for studies that do not collect information on frailty.
Assuntos
Demandas Administrativas em Assistência à Saúde , Estenose da Valva Aórtica/cirurgia , Valva Aórtica/patologia , Calcinose/cirurgia , Fragilidade/mortalidade , Benefícios do Seguro , Medicare , Substituição da Valva Aórtica Transcateter/mortalidade , Idoso , Idoso de 80 Anos ou mais , Valva Aórtica/cirurgia , Estenose da Valva Aórtica/diagnóstico , Estenose da Valva Aórtica/mortalidade , Calcinose/diagnóstico , Calcinose/mortalidade , Comorbidade , Bases de Dados Factuais , Feminino , Idoso Fragilizado , Fragilidade/diagnóstico , Avaliação Geriátrica , Humanos , Masculino , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Substituição da Valva Aórtica Transcateter/efeitos adversos , Resultado do Tratamento , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Assessment of patients with aortic stenosis (AS) and impaired left ventricular function remains challenging. Aortic valve calcium (AVC) scoring with computed tomography (CT) and fluoroscopy has been proposed as means of diagnosing and predicting outcomes in patients with severe AS. HYPOTHESIS: Severity of aortic valve calcification correlates with the diagnosis of true severe AS and outcomes in patients with low-gradient low-flow AS. METHODS: Echocardiography and CT database records from January 1, 2000 to September 26, 2009 were reviewed. Patients with aortic valve area (AVA)<1.0 cm2 who had ejection fraction (EF)≤25% and mean valvular gradient≤25 mmHg with concurrent noncontrast CT scans were included. AVC was evaluated using CT and fluoroscopy. Mortality and aortic valve replacement (AVR) were established using the Social Security Death Index and medical records. The role of surgery in outcomes was evaluated. RESULTS: Fifty-one patients who met the above criteria were included. Mean age was 75.1±9.6 years, and 15 patients were female. Mean EF was 21%±4.6% with AVA of 0.7±0.1 cm2. The peak and mean gradients were 35.5±10.6 and 19.0±5.1 mmHg, respectively. Median aortic valve calcium score was 2027 Agatston units. Mean follow-up was 908 days. Patients with calcium scores above the median value were found to have increased mortality (P=0.02). The benefit of surgery on survival was more pronounced in patients with higher valvular scores (P=0.001). Fluoroscopy scoring led to similar findings, where increased AVC predicted worse outcomes (P=0.04). CONCLUSIONS: In patients with low-gradient low-flow AS, higher valvular calcium score predicts worse long-term mortality. AVR is associated with improved survival in patients with higher valve scores.
Assuntos
Estenose da Valva Aórtica/diagnóstico , Valva Aórtica/patologia , Calcinose/diagnóstico , Idoso , Idoso de 80 Anos ou mais , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/fisiopatologia , Valva Aórtica/cirurgia , Estenose da Valva Aórtica/mortalidade , Estenose da Valva Aórtica/fisiopatologia , Estenose da Valva Aórtica/cirurgia , Calcinose/mortalidade , Calcinose/fisiopatologia , Calcinose/cirurgia , Feminino , Implante de Prótese de Valva Cardíaca , Hemodinâmica , Humanos , Estimativa de Kaplan-Meier , Masculino , Valor Preditivo dos Testes , Fluxo Sanguíneo Regional , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença , Volume Sistólico , Fatores de Tempo , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Ultrassonografia , Função Ventricular EsquerdaRESUMO
OBJECTIVE: Conversion to an open thoracotomy during video-assisted thoracoscopic surgery lobectomy is reported to occur in up to 23% of cases and can be associated with increased morbidity. We developed a preoperative computed tomography calcification score based on anatomic location and extent of calcifications to evaluate the ability to predict video-assisted thoracoscopic surgery conversion. METHODS: Patients undergoing planned video-assisted thoracoscopic surgery lobectomy between 2003 and 2009 were identified. Baseline demographics, comorbidities, operative data, and postoperative outcomes were reviewed. Preoperative chest computed tomography scans were examined by an attending thoracic surgeon. Calcifications were scored from 0 (none) to 6 (major hilar calcifications at the resection bronchus). Preoperative patient and tumor characteristics and the calcification score were analyzed for their ability to predict conversion. We then compared outcomes among patients undergoing video-assisted thoracoscopic surgery, converted video-assisted thoracoscopic surgery, and planned open thoracotomy. RESULTS: Of the 193 patients undergoing planned video-assisted thoracoscopic surgery lobectomy, 148 (77%) had a completed video-assisted thoracoscopic surgery lobectomy, and 45 (23%) underwent conversion to thoracotomy. The calcification score was found to independently predict video-assisted thoracoscopic surgery conversion. Patients who were converted to a thoracotomy had significantly higher 30-day mortality, more atrial arrhythmias, increased blood loss, longer operative time, and increased length of stay compared with those who underwent completed video-assisted thoracoscopic surgery lobectomy and longer length of stay compared with those undergoing planned open lobectomy. CONCLUSIONS: Calcification score based on the location and degree of calcifications can predict the increased likelihood of video-assisted thoracoscopic surgery conversion. This scoring system could be one element used to choose the approach for a lobectomy, especially during a surgeon's learning curve.
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Calcinose/diagnóstico por imagem , Calcinose/cirurgia , Neoplasias Pulmonares/diagnóstico por imagem , Neoplasias Pulmonares/cirurgia , Cirurgia Torácica Vídeoassistida , Toracotomia , Tomografia Computadorizada por Raios X , Idoso , Calcinose/mortalidade , Comorbidade , Feminino , Humanos , Modelos Logísticos , Neoplasias Pulmonares/mortalidade , Masculino , Pessoa de Meia-Idade , Pneumonectomia , Radiografia Torácica , Estudos Retrospectivos , Fatores de Risco , Resultado do TratamentoRESUMO
The Heinz Nixdorf Recall Study is a population-based study that aims to improve the prediction of cardiovascular events by integrating new imaging and non-imaging modalities in risk assessment. One focus of the study is the evaluation of the quantification of subclinical coronary artery calcifications (coronary artery calcification, CAC) as a prognostic factor in predicting cardiac events. Primary endpoints are myocardial infarction and sudden cardiac death. The study was initiated in the late 1990s and enrolled a total of 4,814 participants aged 45-75 years between December 2000 and August 2003. A 5-year follow-up examination took place between 2006 and 2008. Currently, the 10-year follow-up is under way and is estimated to be finished in July 2013. Extending the original aims of the study, serial CAC measurements will allow the characterization of the natural history of CAC dynamics, the identification of its determinants and an understanding of the impact of CAC progression on the primary endpoints. The Heinz Nixdorf Recall Study will significantly extend our knowledge about new modalities in the prediction of cardiac events.
Assuntos
Calcinose/mortalidade , Estudos de Coortes , Doença da Artéria Coronariana/mortalidade , Indicadores Básicos de Saúde , Nível de Saúde , Qualidade de Vida , Idoso , Causalidade , Feminino , Alemanha/epidemiologia , Alemanha Oriental/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Prevalência , Fatores de Risco , Análise de Sobrevida , Taxa de SobrevidaRESUMO
New recommendations put forth in the American College of Cardiology Foundation/American Heart Association (ACC/AHA) Guidelines for Assessment of Cardiovascular Risk in Asymptomatic Adults and the updated 2010 Appropriate Use Criteria for Cardiac Computed Tomography both reflect the unparalleled prognostic power of CAC scoring and it's unique ability to further refine current risk prediction models. The ACCF/AHA guidelines maintain the measurement of CAC is reasonable for cardiovascular risk assessment in asymptomatic adults at intermediate risk (10%-20% 10-year-risk) (IIa, Level of Evidence: B), low-to-intermediate risk (6%-10% 10-year-risk) (IIb, Level of Evidence: B), and in diabetics over age 40 (IIa, Level of Evidence: B). There now exists a large body of published evidence depicting the independent and incremental prognostic value of CAC scoring over Framingham risk score-based strategy alone, a feature unmatched by any other biomarker under investigation. Early detection of subclinical atherosclerosis through noninvasive assessment of CAC leads to more accurate risk stratification and a substantially higher net reclassification improvement (NRI) among intermediate-risk groups, deeming many patients newly eligible for lipid-lowering therapy and other preventative measures.
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Calcinose/diagnóstico por imagem , Calcinose/mortalidade , Angiografia Coronária/estatística & dados numéricos , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/mortalidade , Medicina Baseada em Evidências , Tomografia Computadorizada por Raios X/estatística & dados numéricos , Adulto , Comorbidade , Feminino , Humanos , Masculino , Prevalência , Medição de Risco , Fatores de Risco , Análise de Sobrevida , Taxa de SobrevidaRESUMO
OBJECTIVES: We sought to study the prognostic utility of coronary artery calcium (CAC) in the elderly. BACKGROUND: The prognostic significance of CAC in the elderly is not well known. METHODS: All-cause mortality was assessed in 35,388 patients (3,570 were >or=70 years old at screening, and 50% were women) after a mean follow-up of 5.8 +/- 3 years. RESULTS: In older patients, risk factors and CAC were more prevalent. Overall survival was 97.9% at the end of follow-up. Mortality increased with each age decile with a relative hazard of 1.09 (95% confidence interval: 1.08 to 1.10, p < 0.0001), and rates were greater for men than women (hazard ratio: 1.53; 95% confidence interval: 1.32 to 1.77, p < 0.0001). Increasing CAC scores were associated with decreasing survival across all age deciles (p < 0.0001). Survival for a <40-year and >or=80-year-old man with a CAC score >or=400 was 88% and 19% (95% and 44% for a woman, p < 0.0001), respectively. Among the 20,562 patients with no CAC, annual mortality rates ranged from 0.3% to 2.2% for patients age 40 to 49 years or >or=70 years (p < 0.0001). The use of CAC allowed us to reclassify more than 40% of the patients >or=70 years old more often by excluding risk (i.e., CAC <400) in those with >3 risk factors. CONCLUSIONS: Despite their limited life expectancy, the use of CAC discriminates mortality risk in the elderly. Furthermore, the use of CAC allows physicians to reclassify risk in the elderly.