Severe aortic stenosis: secular trends of incidence and outcomes.

BACKGROUND AND AIMS: Severe aortic stenosis (AS) is the guideline-based indication for aortic valve replacement (AVR), which has markedly increased with transcatheter approaches, suggesting possible increasing AS incidence. However, reported secular trends of AS incidence remain contradictory and lack quantitative Doppler echocardiographic ascertainment. METHODS: All adults residents in Olmsted County (MN, USA) diagnosed over 20 years (1997-2016) with incident severe AS (first diagnosis) based on quantitatively defined measures (aortic valve area ≤ 1 cm2, aortic valve area index ≤ 0.6 cm2/m2, mean gradient ≥ 40 mmHg, peak velocity ≥ 4 m/s, Doppler velocity index ≤ 0.25) were counted to define trends in incidence, presentation, treatment, and outcome. RESULTS: Incident severe AS was diagnosed in 1069 community residents. The incidence rate was 52.5 [49.4-55.8] per 100 000 patient-year, slightly higher in males vs. females and was almost unchanged after age and sex adjustment for the US population 53.8 [50.6-57.0] per 100 000 residents/year. Over 20 years, severe AS incidence remained stable (P = .2) but absolute burden of incident cases markedly increased (P = .0004) due to population growth. Incidence trend differed by sex, stable in men (incidence rate ratio 0.99, P = .7) but declining in women (incidence rate ratio 0.93, P = .02). Over the study, AS clinical characteristics remained remarkably stable and AVR performance grew and was more prompt (from 1.3 [0.1-3.3] years in 1997-2000 to 0.5 [0.2-2.1] years in 2013-16, P = .001) but undertreatment remained prominent (>40%). Early AVR was associated with survival benefit (adjusted hazard ratio 0.55 [0.42-0.71], P < .0001). Despite these improvements, overall mortality (3-month 8% and 3-year 36%), was swift, considerable and unabated (all P ≥ .4) throughout the study. CONCLUSIONS: Over 20 years, the population incidence of severe AS remained stable with increased absolute case burden related to population growth. Despite stable severe AS presentation, AVR performance grew notably, but while declining, undertreatment remained substantial and disease lethality did not yet decline. These population-based findings have important implications for improving AS management pathways.

Clinical presentation and outcome of tricuspid regurgitation in patients with systolic dysfunction.

Aims: The impact of tricuspid regurgitation (TR) in patients with left ventricular systolic dysfunction on presentation and clinical outcome is uncertain due to confounding comorbidities and mediocre regurgitation ascertainment. Methods and results: In a cohort of patients with left ventricular systolic dysfunction (ejection fraction, EF < 50%) and functional TR (assessed quantitatively), we matched TR grade-groups for age, sex, EF, and TR velocity. Association of quantified TR (effective regurgitant orifice, ERO, severe if ≥0.4 cm2) to clinical presentation and outcome was analysed. In the 291 cohort patients (age 70 ± 12 years) with left ventricular dysfunction (EF 31 ± 10%), functional TR ERO was 0.26 ± 0.3 cm2. Presentation with right heart failure was strongly related to TR quantified severity [adjusted odds ratios were 4.15 (1.95-8.84), P = 0.0002 for moderate TR and 6.86 (3.34-14.1), P < 0.0001 for severe TR]. Effective regurgitant orifice ≥0.4 cm2 was associated with increased mortality [hazard ratio 1.6 (1.17-2.2), P = 0.003] unadjusted and after comprehensive adjustment [hazard ratio 1.8 (1.16-2.8), P = 0.009]. Furthermore, ERO ≥0.4 cm2 was associated with increased cardiac events (mortality, new atrial fibrillation or heart failure) unadjusted [hazard ratio 1.9 (1.3-2.7), P = 0.002] and after comprehensive adjustment [hazard ratio 2.2 (1.1-4.6), P = 0.02]. Conclusion: Tricuspid regurgitation, even moderate, is associated at diagnosis with more severe heart failure presentation. While moderate TR is associated with heart failure at presentation, our quantitative data show that the threshold associated with reduced survival and more cardiac events is ERO ≥0.4 cm2. These data emphasize the clinical impact of functional TR and warrant large cohort-analysis and clinical trials of treatment of TR associated with left ventricular dysfunction.

Severity of Depressive Symptoms Pre- and Postcardiac Rehabilitation: A COMPARISON AMONG PATIENTS IN BRAZIL, CANADA, COLOMBIA, THE UNITED STATES, AND VENEZUELA.

PURPOSE: Depression is 3 times more prevalent in the cardiac than the general population in high-income countries and is particularly high in middle-income countries. Comorbid depression is associated with twice the mortality after a cardiovascular event. The objectives of this study were to describe and compare depressive symptoms pre- and postcardiac rehabilitation (CR) among patients in high-income countries and middle-income countries in the Americas. METHODS: The study design was prospective and observational. A convenience sample of CR participants completed the Patient Health Questionnaire-9 (PHQ-9) at CR intake and again at program discharge. Clinical data were extracted from medical charts. RESULTS: There were 779 participants: 45 Brazilian (5.8% of sample), 214 Canadian (27.5%), 126 Colombian (16.2%), 309 American (39.7%), and 85 Venezuelan (10.9%). Pre-CR depressive symptoms significantly differed between countries (P < .05), with Colombian participants reporting higher scores than Canadians and Venezuelans. Total PHQ-9 scores significantly decreased during CR in Colombia (mean change =-2.33; P < .001), the United States (mean change =-1.12; P < .001), and Venezuela (mean change =-2.14; P < .001), but not in Brazil (where less psychosocial intervention was offered) or Canada (where pre-CR scores were low). Among the 102 (13.1%) participants with scores in the elevated range pre-CR, the mean change in PHQ-9 scores was -6.57 ± 1.09 and 40 (39.2%) participants no longer had elevated symptoms postprogram. CONCLUSIONS: Depressive symptoms are variable among patients with CR in South and North American countries. CR programs incorporating psychosocial components can reduce these symptoms.