Prevalence of coronary artery disease in patients with aortic stenosis with and without angina pectoris

The growing number of candidates for transcatheter aortic valve replacement (TAVR) has increased the interest in the concomitant presence of coronary artery disease (CAD) and severe aortic stenosis (AS), prompting the need to define the appropriate revascularization strategy for each case. The reported prevalence of concurrent AS and CAD has varied over the years on the basis of the CAD definition and the population evaluated. Revascularization for treating CAD in patients with severe AS involves additional interventions that could impact outcomes. The addition of coronary artery bypass grafting (CABG) to surgical aortic valve replacement (SAVR) has demonstrated favourable effects on long-term prognosis, while the impact of adding percutaneous coronary intervention (PCI) to TAVR may depend on the CAD complexity and the feasibility of achieving complete or reasonably incomplete revascularization. Furthermore, the comparison between SAVR+CABG and TAVR+PCI in low-intermediate surgical risk and low-intermediate complex CAD patients did not reveal differences in all-cause mortality or stroke between the groups. However, there is some evidence showing a lower incidence of major cardiovascular events with the SAVR+CABG strategy for patients with complex CAD. Thus, SAVR+CABG seems to be the best option for patients with low-intermediate surgical risk and complex CAD, and TAVR+PCI for high surgical risk patients seeking complete and/or reasonable incomplete revascularization. After deciding between TAVR+PCI or SAVR+CABG, factors such as timing for PCI, low ejection fraction, coronary reaccess, and valve durability must be considered. Finally, alternative methods for assessing CAD severity are currently under evaluation to ascertain their real value for guiding revascularization in patients with severe AS with CAD.

Le nombre croissant de patients appelés à subir un remplacement valvulaire aortique par cathéter (RVAC) a suscité un intérêt grandissant dans les cas de maladie coronarienne et de sténose aortique (SA) sévère concomitantes, d’où le besoin de définir une stratégie de revascularisation appropriée à chaque cas. La prévalence déclarée des cas de SA et de maladie coronarienne concomitantes a varié au cours des années en fonction de la définition de la maladie coronarienne et de la population évaluée. Le recours à la revascularisation pour le traitement de la maladie coronarienne chez les patients présentant une SA sévère exige des interventions additionnelles susceptibles d’influer sur les résultats. Ainsi, un pontage aortocoronarien (PAC) pratiqué en plus d’une chirurgie de remplacement valvulaire aortique (CRVA) a démontré des effets favorables sur le pronostic à long terme, alors que l’effet d’ajouter une intervention coronarienne percutanée (ICP) a un RVAC pourrait dépendre de la complexité de la maladie coronarienne et de la faisabilité d’une revascularisation complète, ou incomplète mais acceptable. En outre, la comparaison entre les stratégies CRVA + PAC et RVAC + ICP chez les patients présentant un risque chirurgical faible ou intermédiaire et une maladie coronarienne complexe légère ou intermédiaire n’a pas révélé de différence entre les groupes en ce qui concerne la mortalité de toutes causes ou la survenue d’accidents vasculaires cérébraux. Cependant, certaines données montrent une incidence plus faible de manifestations cardiovasculaires graves avec la stratégie CRVA + PAC chez les patients atteints d’une maladie coronarienne complexe. Ainsi, la stratégie CRVA + PAC semble être le meilleur choix pour les patients présentant un risque chirurgical faible ou intermédiaire et une maladie coronarienne complexe, alors que la stratégie RVAC + ICP serait davantage indiquée pour les patients présentant un risque chirurgical élevé qui veulent une revascularisation complète, ou incomplète mais acceptable. Après avoir choisi entre les stratégies CRVA + PAC et RVAC + ICP, il faut tenir compte de divers facteurs : moment où l’ICP sera pratiquée, fraction d’éjection faible, reperméabilisation coronarienne et durabilité de la valve. Enfin, d’autres méthodes destinées à déterminer la gravité de la maladie coronarienne font actuellement l’objet d’une évaluation visant à vérifier leur valeur réelle pour guider les décisions en matière de revascularisation pour les patients présentant une SA sévère et une maladie coronarienne concomitantes.

Evaluar la prevalencia, las características clínicas y el impacto de la angina en pacientes con estenosis aórtica sometidos a implante percutáneo de válvula aórtica (TAVI).

Se analizó a 1.687 pacientes consecutivos con estenosis aórtica sometidos a TAVI, clasificados en función de la presencia o ausencia basal de angina. Los datos basales, del procedimiento y del seguimiento se recogieron en una base de datos local.

Un total de 497 pacientes (29%) presentaban angina antes del TAVI. Los pacientes con angina basal presentaban peor clase funcional (NYHA > II, el 69% frente al 63%; p = 0,017) y una mayor prevalencia de enfermedad coronaria (el 74% frente al 56%; p < 0,001). La angina basal no mostró impacto pronóstico a 1 año en mortalidad por cualquier causa (HR = 1,02; IC95%, 0,71-1,48; p = 0,898) ni en mortalidad cardiovascular (HR = 1,2; IC95%, 0,69-2,11; p = 0,517). Sin embargo, la persistencia de angina 30 días después del procedimiento se asoció con un incremento en la mortalidad a 1 año, tanto total (HR = 4,86; IC95%, 1,71-13,8; p = 0,003) como de causa cardiovascular (HR = 20,7; IC95%, 3,50-122,6; p = 0,001).

Más de un cuarto de los pacientes con estenosis aórtica sometidos a TAVI tenían angina antes del procedimiento. La angina basal no mostró impacto pronóstico alguno. Sin embargo, la persistencia de angina 30 días después del procedimiento se asoció con una mayor mortalidad al año.

To evaluate the prevalence, clinical characteristics, and outcomes of patients with angina undergoing transcatheter aortic valve replacement (TAVR) for severe aortic stenosis.

A total of 1687 consecutive patients with severe aortic stenosis undergoing TAVR at our center were included and classified according to patient-reported angina symptoms prior to the TAVR procedure. Baseline, procedural and follow-up data were collected in a dedicated database.

A total of 497 patients (29%) had angina prior to the TAVR procedure. Patients with angina at baseline showed a worse New York Heart Association (NYHA) functional class (NYHA class > II: 69% vs 63%; P = .017), a higher rate of coronary artery disease (74% vs 56%; P < .001), and a lower rate of complete revascularization (70% vs 79%; P < .001). Angina at baseline had no impact on all-cause mortality (HR, 1.02; 95%CI, 0.71-1.48; P = .898) and cardiovascular mortality (HR, 1.2; 95%CI, 0.69-2.11; P = .517) at 1 year. However, persistent angina at 30 days post-TAVR was associated with increased all-cause mortality (HR, 4.86; 95%CI, 1.71-13.8; P = .003) and cardiovascular mortality (HR, 20.7; 95%CI, 3.50-122.6; P = .001) at 1-year follow-up.

More than one-fourth of patients with severe aortic stenosis undergoing TAVR had angina prior to the procedure. Angina at baseline did not appear to be a sign of a more advanced valvular disease and had no prognostic impact; however, persistent angina at 30 days post-TAVR was associated with worse clinical outcomes.

The prognostic impact of coronary artery disease (CAD) after transcatheter aortic valve implantation (TAVI) is controversial. The aim of this study is to investigate the impact of CAD and different revascularization strategies on clinical outcomes in patients who underwent TAVI with third generation devices. Patients enrolled in the national observational Observational Study of Effectiveness of SAVR-TAVI Procedures for Severe Aortic Stenosis Treatment II study were stratified according to the presence of CAD (CAD+, n = 1,130) versus no CAD (CAD−, n = 1,505), and compared using a propensity matched analysis. CAD+ group was further stratified according to the revascularization strategy: no revascularization (n = 331), revascularization performed >90 days before index-TAVI (n = 417) and coronary revascularization performed <90 days before index-TAVI or during TAVI (n = 382). In-hospital, 30-day and 1-year clinical outcomes were estimated. The mean age of the overall population was 81.8 years; 54.9% of patients were female. Propensity score matching yielded 813 pairs and their 30-day all-cause mortality was comparable (p = 0.480). Major periprocedural adverse events were also similar between the groups. At 1-year follow-up, the rate of major adverse cardiac and cerebrovascular events (MACCEs) and all-cause mortality were similar between the groups (p = 0.732 and p = 0.633, respectively). Conversely, patients with CAD experienced more often myocardial infarction and need for percutaneous coronary intervention at 1 year (p = 0.007 and p = 0.001, respectively). Neither CAD nor revascularization strategy were independent predictors of 1-year MACCE. About 40% of patients presenting with severe AS and who underwent TAVI had concomitant CAD. The presence of CAD had no impact on all-cause mortality and MACCE 1-year after TAVR. However, CAD carries a higher risk for acute myocardial infarction and need of percutaneous coronary intervention during follow-up.

The “2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease” provides an update to and consolidates new evidence since the “2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease” and the corresponding “2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease.”

A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost–value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

La enfermedad coronaria (EC) se encuentra en el 30-50% de los pacientes con estenosis aórtica (EA) grave que reciben tratamiento intervencionista. Todavía no está claro cuál es el mejor tratamiento de la EAC en pacientes con EA sometidos a implante percutáneo de válvula aórtica (TAVI). El objetivo del estudio fue analizar el impacto clínico del miocardio en riesgo en pacientes con EAC y EA grave tratados con TAVI.

Se incluyó a pacientes consecutivos sometidos a TAVI en nuestro hospital. En presencia de EAC, el miocardio en riesgo antes del procedimiento se clasificó utilizando la puntuación de riesgo (JS) de la British Cardiovascular Intervention Society (BCIS). La población de estudio se dividió en 3 grupos: pacientes sin EAC concomitante (grupo No-EAC), pacientes con EAC y BCIS-JS ≤ 4 (grupo EAC BCIS-JS ≤ 4) y pacientes con EAC concomitante y BCIS-JS > 4 (grupo EAD BCIS -JS > 4). El objetivo primario del estudio fueron los eventos cardiovasculares y cerebrovasculares adversos mayores (MACCE).

Se incluyó a un total de 403 pacientes: 223 No-EAD, 94 EAC BCIS-JS ≤ 4 y 86 EAC BCIS-JS > 4. Con 3 meses de seguimiento [rango 104 – 3.296 días], los pacientes sin EAC y los pacientes con EAC con BCIS-JS ≤ 4 tuvieron una mejor supervivencia libre de MACCE en comparación con aquellos con revascularización menos extensa (BCIS-JS > 4) (p = 0,049). Este resultado se debió en parte a una reducción significativa de la mortalidad (p = 0,031). En el análisis multivariado, el BCIS-JS residual ≤ 4 y la clase III-IV de la NYHA predijeron MACCE de forma independiente.

En pacientes con EAC y EA grave, la extensión del miocardio en riesgo antes del TAVI influye en los resultados clínicos.

Coronary artery disease (CAD) is found in 30%-50% of patients with severe aortic stenosis (AS) undergoing treatment. The best management of CAD in AS patients undergoing transcatheter aortic valve implantation (TAVI) is still unclear. We investigated the clinical impact of the extent of jeopardized myocardium in patients with concomitant CAD and severe AS treated by TAVI.

Consecutive patients who underwent TAVI procedures at our hospital were identified. In the presence of CAD, the myocardium jeopardized before TAVI was graded using the British Cardiovascular Intervention Society (BCIS) jeopardy score (JS). The study population was divided in 3 groups: patients without concomitant CAD (no-CAD), patients with CAD and BCIS-JS ≤ 4 (CAD BCIS-JS ≤ 4) and patients with concomitant CAD and BCIS-JS > 4 (CAD BCIS-JS > 4). The primary study endpoint was major adverse cardiovascular and cerebrovascular events (MACCE).

A total of 403 patients entered the study: 223 no-CAD, 94 CAD BCIS-JS ≤ 4 and 86 CAD BCIS-JS > 4. At > 3 months of follow-up [range 104–3296 days], patients without CAD and CAD patients with BCIS-JS ≤ 4 had better survival free from MACCE compared with those with less extensive revascularization (BCIS-JS > 4) (P = .049). This result was driven by a significant reduction in death (P = .031). On multivariate analysis, residual BCIS-JS ≤ 4 and NYHA class III-IV independently predicted MACCE.

In patients with concomitant CAD and severe AS, the extent of jeopardized myocardium before TAVI impacts on clinical outcomes.

The study objective was to analyze temporal changes in baseline and procedural characteristics and long-term survival of patients undergoing surgical aortic valve replacement over a 30-year period.

A retrospective analysis of patients undergoing surgical aortic valve replacement between 1987 and 2016 in the Erasmus Medical Center (Rotterdam, The Netherlands) was conducted. Patient baseline and procedural characteristics were analyzed in periods according to the date of surgical aortic valve replacement (period A: 1987-1996; B: 1997-2006; C: 2007-2016). Survival status was determined using the Dutch National Death Registry. Relative survival was obtained by comparing the survival after surgical aortic valve replacement with the survival of the age-, sex-, and year-matched general population.

Between 1987 and 2016, 4404 patients underwent SAVR. From period A to C, the mean age increased from 63.9 ± 11.2 years to 66.2 ± 12.3 years (P < .001), and the prevalence of diabetes mellitus, hypertension, hypercholesterolemia, previous myocardial infarction, and previous stroke at baseline increased (P values for trend for all < .001). The prevalence of concomitant procedures increased from 42.4% in period A to 48.3% in period C (P = .004). Bioprosthesis use increased significantly (18.8% in period A vs 67.1% in period C, P < .001). Mean survival after surgical aortic valve replacement was 13.8 years. Relative survival at 20 years in the overall cohort was 60.4% (95% confidence interval, 55.9-65.2) and 73.8% (95% confidence interval, 67.1-81.1) in patients undergoing isolated primary surgical aortic valve replacement.

Patient complexity has been continuously increasing over the last 30 years, yet long-term survival after surgical aortic valve replacement remains high compared with the age-, sex-, and year-matched general population.