Unique Aspects of Women's Valvular Heart Diseases: Impact for Diagnosis and Treatment.

Valvular heart diseases (VHDs) are a major cause of cardiovascular morbidity and mortality worldwide. As degenerative and functional mechanisms represent the main etiologies in high-income countries are degenerative and functional, while in low income countries etiologie is mostly rheumatic. Although therapeutic options have evolved considerably in recent years, women are consistently diagnosed at later stages of their disease, are delayed in receiving surgical referrals, and exhibit worse postoperative outcomes, compared to men. This difference is a result of the historical underrepresentation of women in studies from which current guidelines were developed. However, in recent years, important research, including more female patients, has been conducted and has highlighted substantial sex-specific differences in the etiology, diagnosis, and treatment of VHDs. Systematic consideration of these sex-specific differences in VHD patients is crucial for providing equitable healthcare and optimizing clinical outcomes in both female and male patients. Hence, this review aims to explore implications of sex-specific particularities for diagnosis, treatment options, and outcomes in women with VHDs.

Les valvulopathies sont une cause majeure de morbidité cardiovasculaire et de mortalité dans le monde. Les mécanismes dégénératifs et fonctionnels représentent maintenant les principales étiologies dans les pays à revenu élevé, mais la maladie valvulaire rhumatismale demeure très prévalente dans les pays à revenu faible. Par ailleurs, même si les options thérapeutiques ont évolué depuis quelques années, les femmes reçoivent systématiquement leur diagnostic à des stades plus avancés de la maladie, sont orientées plus tard en chirurgie et les issues postopératoires sont moins favorables par rapport aux hommes. Cette différence s'explique par une sous-représentation historique des femmes dans les études sur lesquelles reposent les lignes directrices actuelles. Cependant, des études importantes réalisées ces dernières années ont mis au jour des différences substantielles entre les sexes en ce qui a trait à l'étiologie, au diagnostic et au traitement des valvulopathies. Il est essentiel de tenir compte des différences selon le sexe chez les patients atteints d'une valvulopathie pour fournir des soins de santé équitables et optimiser l'issue clinique tant chez les femmes que chez les hommes. Cette analyse vise donc à explorer les implications des particularités selon le sexe en ce qui concerne le diagnostic, les options thérapeutiques et les issues chez les femmes atteintes de valvulopathies.

Angiotensin II receptor blockers are associated with reduced valvular fibrosis in females with aortic stenosis.

BACKGROUND: Angiotensin receptor blockers (ARBs) may slow down the progression of aortic stenosis (AS), through their antifibrotic effect. Females present more valvular fibrosis than males, thus ARBs may have more effect in females. Our aim was to assess the impact of ARBs on the remodeling of the aortic valve in males and females. METHODS: We included patients who had an aortic valve replacement± coronary bypass grafting between 2006-2013. Patients with missing echocardiographic or histologic data were excluded. Warren-Yong and fibrosis scores of the explanted valves were performed. Patients were divided into four phenotypes according to their Warren-Yong and fibrosis scores: Mild calcification/fibrosis group, Severe calcification/fibrosis group, Predominant fibrosis group, Predominant calcification group. RESULTS: Among the 1,321 included patients, the vast majority (89%) has severe AS. Patients in the predominant fibrosis group, as compared to the predominant calcium group, were more often females (39 vs 31%, p=0.008), bicuspid valves (44 vs 34%, p=0.002) and they less often used ARBs (25 vs 30%, p=0.046). Female sex was independently associated with being in the predominant fibrosis group (OR 1.45 [95% CI 1.08-1.95], p=0.01), with a significant interaction between female sex and ARBs. Females taking ARBs compared to females not taking ARBs had significantly lower fibrosis score (p<0.001). This difference was not seen in males. CONCLUSION: In this large series of patients with moderate-severe AS, among females there was a negative association between intake of ARBs and valvular fibrosis. Thus, the possible effects of ARBs may be sex-specific, with a larger therapeutic role in females.

Prevalence and Outcomes of Patients With Discordant High-Gradient Aortic Stenosis.

BACKGROUND: Conflicting prognostic results have been reported in patients with discordant high-gradient aortic stenosis ([DHG-AS] the combination of a mean pressure gradient ≥40 mm Hg and an aortic valve area [AVA] >1 cm2). Moreover, existing studies only included selected patients without concomitant aortic regurgitation. OBJECTIVES: The authors assessed the prevalence and survival of patients presenting with DHG-AS in an unselected group of consecutive patients presenting to the echocardiography laboratory of a tertiary referral center. METHODS: A total of 3,547 adult patients with AVA ≤1.5 cm2 and peak aortic jet velocity ≥2.5 m/s or mean gradient ≥25 mm Hg who presented between 2005 and 2015 were included. Baseline clinical and echocardiographic data, and, when available, aortic valve calcium (AVC) score were collected in an institutional database, with subsequent retrospective analysis. The primary endpoint was all-cause mortality during follow-up. RESULTS: DHG-AS was observed in 163 patients (11.6% of patients with a high gradient). After adjustment for potential confounders, overall mortality rate of patients with DHG-AS was similar to that of patients with concordant severe aortic stenosis (HR: 0.98 [95% CI: 0.66-1.44]; P = 0.91), and patients with discordant low-gradient aortic stenosis (HR: 0.85 [95% CI: 0.58-1.26]; P = 0.42), and higher than concordant moderate aortic stenosis (HR: 0.54 [95% CI: 0.36-0.81]; P = 0.003). After adjustment for aortic velocities, aortic regurgitation had no significant impact on survival. AVC was higher than in patients with concordant moderate aortic stenosis and discordant low-gradient aortic stenosis, and not significantly different from that of concordant severe aortic stenosis. CONCLUSIONS: DHG-AS is not uncommon. Whereas AVA >1.0 cm2 is often seen as moderate aortic stenosis, a high-pressure gradient conveys a poor prognosis, whatever the AVA and the severity of concomitant aortic regurgitation.