Effect of age and aortic valve anatomy on calcification and haemodynamic severity of aortic stenosis

OBJECTIVE: To evaluate the effect of age and aortic valve anatomy (tricuspid (TAV) vs bicuspid (BAV) aortic valve) on the relationship between the aortic valve calcification (AVC) and the haemodynamic parameters of aortic stenosis (AS) severity. METHODS: Two hundred patients with AS and preserved left ventricular ejection fraction were prospectively recruited in the PROGRESSA (Metabolic Determinants of the Progression of Aortic Stenosis) study and underwent a comprehensive Doppler echocardiography and multidetector CT (MDCT). Mean transvalvular gradient (MG) measured by Doppler echocardiography was used to assess AS haemodynamic severity and AVC was evaluated by MDCT using the Agatston method and indexed to the left ventricular outflow tract area to obtain AVC density (AVCd). All analyses were adjusted for sex. RESULTS: Thirty-nine patients had a BAV and 161 a TAV. Median age was 51 and 72 years for BAV and TAV patients, respectively. There was a modest correlation between MG and AVCd (p=0.51, p<0.0001) in the whole cohort. After dichotomisation for valve anatomy, there was a good correlation between AVCd and MG in the TAV group (p=0.61, p<0.0001) but weak correlation in the BAV group (p=0.32, p=0.046). In the TAV group, the strength of the AVCd-MG correlation was similar in younger (<72 years old; p=0.59, p<0.0001) versus older (=72 years old; p=0.61, p<0.0001) patients. In the BAV group, there was no correlation between AVCd and MG in younger patients (<51 years old; p=0.12, p=0.65), whereas there was a good correlation in older patients (=51 years old; p=0.55, p=0.009). AVCd (p=0.005) and age (p=0.02) were both independent determinants of MG in BAV patients while AVCd (p<0.0001) was the only independent determinant of MG in TAV patients. CONCLUSIONS: In patients with TAV as well as in older patients with BAV, AVCd appears to be the main factor significantly associated with the haemodynamic severity of AS and so it may be used to corroborate AS severity in case of uncertain or discordant findings at echocardiography. However, among younger patients with BAV, some may have a haemodynamically significant stenosis with minimal AVCd. The results of MDCT AVCd should thus be interpreted cautiously in this subset of patients

Effect of regional upper septal hypertrophy on echocardiographic assessment of left ventricular mass and remodeling in aortic stenosis

Transthoracic echocardiography (TTE) is the reference method for evaluation of aortic stenosis (AS), and it is extensively used to quantitate left ventricular (LV) mass and volumes. Regional upper septal hypertrophy (USH) or septal bulge is a frequent finding in patients with AS and may lead to overestimation of LV mass when using linear measurements. The objective of this study was to compare estimates of LV mass obtained by two-dimensional transthoracic echocardiographic LV dimensions measured at different levels of the LV cavity with those obtained by cardiovascular magnetic resonance (CMR). Methods: One hundred six patients (mean age, 63 6 15 years; 68% men) with AS were included in this subanalysis of the PROGRESSA study. Two-dimensional transthoracic echocardiographic measurements of LV dimensions were obtained at the basal level (BL; as recommended in guidelines), immediately below the septal bulge (BSB), and at a midventricular level (ML). Regional USH was defined as a basal interventricular septal thickness $ 13 mm and >1.3 times the thickness of the septal wall at the ML. Agreement between transthoracic echocardiographic and CMR measures was evaluated using Bland-Altman analysis. Results: The distribution of AS severity was mild in 23%, moderate in 57%, and severe in 20% of patients. Regional USH was present in 28 patients (26%). In the whole cohort, two-dimensional TTE overestimated LV mass (bias: BL, +60 6 31 g; BSB, +59 6 32 g; ML, +54 6 32 g; P = .02). The biplane Simpson method slightly but significantly underestimated LV end-diastolic volume (bias 10 6 20 mL, P < .001) compared with CMR. Overestimation of LV mass was more marked in patients with USH when measuring at the BL and was significantly lower when measuring LV dimensions at the ML (P < .025 vs BL and BSB). Conclusions: Two-dimensional TTE systematically overestimated LV mass and underestimated LV volumes compared with CMR. However, the bias between TTE and CMR was less important when measuring at the ML. Measurements at the BL as suggested in guidelines should be avoided, and measurements at the ML should be preferred in patients with AS, especially in those with USH

Visceral adiposity and left ventricular mass and function in patients with aortic stenosis : the PROGRESSA study

Background : Recent studies have reported that obesity, metabolic syndrome, and diabetes are associated with left ventricular (LV) hypertrophy (LVH) and dysfunction in patients with aortic stenosis (AS). The purpose of this study was to examine the association between amount and distribution of body fat and LVH and systolic dysfunction in AS patients. Methods : One hundred twenty-four patients with AS were prospectively recruited in the PROGRESSA (Metabolic Determinants of the Progression of Aortic Stenosis) study and underwent Doppler echocardiography and computed tomography scan. Presence and severity of LVH was assessed according to LV mass indexed for height2.7 and LV dysfunction according to global longitudinal strain (GLS). Computed tomography was used to quantify abdominal visceral (VAT) and subcutaneous (SAT) adipose tissue, and total adipose tissue (TAT). Results : Body mass index (BMI) correlated strongly with TAT (r = 0.85), moderately with VAT (r = 0.70), and SAT (r = 0.69), and weakly with the proportion of VAT (VAT/TAT ratio: r = 0.19). In univariate analysis, greater BMI, TAT, VAT, SAT, and VAT/TAT were associated with increased LV mass index and greater VAT and VAT/TAT ratio were associated with reduced GLS. Multivariate analysis revealed that larger BMI (P < 0.0001) and greater VAT/TAT ratio (P = 0.01) were independently associated with higher prevalence of LVH, and only the VAT/TAT ratio (P = 0.03) was independently associated with reduced GLS. Conclusions : The results of this study suggest that total and visceral adiposity are independently associated with LVH in patients with AS. Furthermore, impairment of LV systolic function does not appear to be influenced by total obesity but is rather related to excess visceral adiposity. These findings provide impetus for elaboration of interventional studies aiming at visceral adiposity in the AS population.De récentes études ont rapporté que l’obésité, le syndrome métabolique et le diabète étaient associés à l’hypertrophie (HVG) et à la dysfonction ventriculaire gauche des patients souffrant d’une sténose aortique (SA). Le but de cette étude était d’examiner le lien entre la quantité et la répartition de la graisse corporelle, l’HVG et la dysfonction systolique chez les patients souffrant d’une SA. Méthodes : Cent vingt-quatre patients souffrant d’une SA ont été recrutés de manière prospective dans l’étude PROGRESSA (Metabolic Determinants of the Progression of Aortic Stenosis), et ont subi une échocardiographie Doppler et une tomodensitométrie. La présence et la sévérité de l’HVG ont été évaluées au moyen de la masse VG indexée par la taille2.7 et la dysfonction systolique du VG par la déformation longitudinale globale du VG (DLG). La tomodensitométrie a été utilisée pour quantifier le tissu adipeux abdominal viscéral (TAV) et sous-cutané (TAS), et le tissu adipeux total (TAT). Résultats : L’indice de masse corporelle (IMC) corrélait fortement avec le TAT (r = 0,85), modérément avec le TAV (r = 0,70) et le TAS (r = 0,69), et faiblement avec la proportion de TAV (rapport TAV/TAT : r = 0,19). En analyse multivariée, des IMC, TAT, TAV, TAS et VAT/TAT plus élevés étaient associés à une augmentation de la masse VG indexée et un TAV et un rapport TAV/TAT plus élevés étaient associés à la réduction de la DLG. L’analyse multivariée a révélé qu’un IMC plus élevé (P < 0,0001) et un rapport TAV/TAT plus élevé (P = 0,01) étaient indépendamment associés à une HVG plus importante, et seul un rapport TAV/TAT était indépendamment associé à une réduction de la DLG. Conclusions : Les résultats de cette étude montrent que l’adiposité totale et l'adiposité viscérale sont indépendamment associées à une HVG chez les patients souffrant d’une SA. De plus, la détérioration de la fonction systolique VG ne semble pas être influencée par l’obésité totale, mais est plutôt liée à une adiposité viscérale excessive. Ces résultats incitent à l’élaboration d’études interventionnelles visant l’adiposité viscérale dans la population souffrant de SA

Prevalence of physical and verbal aggressive behaviours and associated factors among older adults in long-term care facilities

BACKGROUND: Verbal and physical aggressive behaviours are among the most disturbing and distressing behaviours displayed by older patients in long-term care facilities. Aggressive behaviour (AB) is often the reason for using physical or chemical restraints with nursing home residents and is a major concern for caregivers. AB is associated with increased health care costs due to staff turnover and absenteeism. METHODS: The goals of this secondary analysis of a cross-sectional study are to determine the prevalence of verbal and physical aggressive behaviours and to identify associated factors among older adults in long-term care facilities in the Quebec City area (n = 2 332). RESULTS: The same percentage of older adults displayed physical aggressive behaviour (21.2%) or verbal aggressive behaviour (21.5%), whereas 11.2% displayed both types of aggressive behaviour. Factors associated with aggressive behaviour (both verbal and physical) were male gender, neuroleptic drug use, mild and severe cognitive impairment, insomnia, psychological distress, and physical restraints. Factors associated with physical aggressive behaviour were older age, male gender, neuroleptic drug use, mild or severe cognitive impairment, insomnia and psychological distress. Finally, factors associated with verbal aggressive behaviour were benzodiazepine and neuroleptic drug use, functional dependency, mild or severe cognitive impairment and insomnia. CONCLUSION: Cognitive impairment severity is the most significant predisposing factor for aggressive behaviour among older adults in long-term care facilities in the Quebec City area. Physical and chemical restraints were also significantly associated with AB. Based on these results, we suggest that caregivers should provide care to older adults with AB using approaches such as the progressively lowered stress threshold model and reactance theory which stress the importance of paying attention to the severity of cognitive impairment and avoiding the use of chemical or physical restraints

Évaluation d'une intervention non pharmacologique pour réduire l'agitation verbale chez les personnes atteintes de démence

L'agitation verbale (AV) est un symptôme comportemental couramment associé à la démence. Elle réfère à des comportements verbaux ou vocaux qui sont répétitifs, dérangeants ou inappropriés au contexte comme les cris, les demandes répétitives et les jurons. En plus d'occasionner de la détresse psychologique chez les soignants, l'AV augmente le niveau d'incapacité des patients, précipite leur institutionnalisation et réduit la qualité des soins qu'ils reçoivent. Plusieurs facteurs peuvent être à l'origine de l'AV et celle-ci peut être interprétée, entre autres, comme la manifestation de besoins insatisfaits. Les appuis empiriques sur le traitement de l'AV sont limités et les interventions reposent rarement sur les causes du comportement. Le développement de stratégies efficaces pour gérer l'AV est essentiel pour améliorer les soins offerts aux patients ainsi que leur qualité de vie et celle de leurs soignants. Cette thèse vise à évaluer l'efficacité d'une intervention reposant sur le modèle des comportements suscités par des besoins compromis par la démence pour réduire l'AV, de même qu'à identifier les caractéristiques associées à la réponse à l'intervention. La thèse comprend trois chapitres. Le Chapitre 1 propose une introduction générale au phénomène de la démence et des symptômes comportementaux qui y sont associés puis plus spécifiquement de l'AV. Le Chapitre 2 présente le contexte, la méthodologie, les résultats et la discussion de l'étude empirique évaluant l'intervention (article scientifique). Les résultats de cette étude montrent que: (a) l'intervention est associée à une réduction de la durée de l'AV; (b) cet effet est limité au moment où le traitement est appliqué; (c) l'amélioration est importante sur le plan comportemental chez plus de la moitié des participants et; (d) la réponse à l'intervention est influencée par des caractéristiques du participant et de son AV. Finalement, le Chapitre 3 conclut sur la place de cette thèse parmi les connaissances actuellement disponibles sur la gestion des symptômes comportementaux et cognitifs associés à la démence et propose des recommandations pour améliorer l'intervention et les recherches futures

Intervention non pharmacologique pour réduire l'agitation verbale : une étude préliminaire

Cette étude a pour objectif d’évaluer l’efficacité d’une intervention comprenant de l’agitation verbale (AV) chez des personnes atteintes de démence et résidant en centre d’hébergement et de soins de longue durée. Un protocole AB à niveaux de bases multiples est appliqué auprès de deux participants. La fréquence et la durée de l’AV ont été mesurées par le décodage d’enregistrements sonores. Une diminution non significative de la durée et une participant, l’analyse des graphiques, des moyennes et des médianes montrent une réduction de l’AV qui ne s’avère pas statistiquement significative. Les résultats suggèrent q’une intervention visant à combler des besoins d’attentioq de confort et de stimulation sensorielle peut contribuer à réduite les comportements d’AV chez certaines personnes mais non chez d’autres

Progression of AS in patients with BAV and TAV

Aims: To compare the progression of aortic stenosis (AS) in patients with bicuspid aortic valve (BAV) or tricuspid aortic valve (TAV). Methods and results: One hundred and forty-one patients with mild-to-moderate AS, recruited prospectively in the PROGRESSA study, were included in this sub-analysis. Baseline clinical, Doppler echocardiography and multidetector computed tomography characteristics were compared between BAV (n = 32) and TAV (n = 109) patients. The 2-year haemodynamic [i.e. peak aortic jet velocity (Vpeak) and mean transvalvular gradient (MG)] and anatomic [i.e. aortic valve calcification density (AVCd) and aortic valve calcification density ratio (AVCd ratio)] progression of AS were compared between the two valve phenotypes. The 2-year progression rate of Vpeak was: 16 (−0 to 40) vs. 17 (3–35) cm/s, P = 0.95; of MG was: 1.8 (−0.7 to 5.8) vs. 2.6 (0.4–4.8) mmHg, P = 0.56; of AVCd was 32 (2–109) vs. 52 (25–85) AU/cm2, P = 0.15; and of AVCd ratio was: 0.08 (0.01–0.23) vs. 0.12 (0.06–0.18), P = 0.16 in patients with BAV vs. TAV. In univariable analyses, BAV was not associated with AS progression (all, P ≥ 0.26). However, with further adjustment for age, AS baseline severity, and several risk factors (i.e. sex, history of hypertension, creatinine level, diabetes, metabolic syndrome), BAV was independently associated with faster haemodynamic (Vpeak: β = 0.31, P = 0.02) and anatomic (AVCd: β = 0.26, P = 0.03 and AVCd ratio: β = 0.26, P = 0.03) progression of AS. Conclusion: In patients with mild-to-moderate AS, patients with BAV have faster haemodynamic and anatomic progression of AS when compared to TAV patients with similar age and risk profile. This study highlights the importance and necessity to closely monitor patients with BAV and to adequately control and treat their risk factors

Bone density and progression of aortic valve stenosis

Background Recent data suggest that there may be an association between low bone mineral density (BMD) and/or altered bone metabolism and calcific aortic stenosis (AS). We examined the association between BMD and faster hemodynamic and anatomic progression rate of AS. Methods and Results One hundred ninety-four patients (65±13 years, 71% men) with AS prospectively recruited in the PROGRESSA study were included in this sub-analysis. Patients underwent Doppler-echocardiography and within 3 months, a multidetector computed tomography (MDCT) exam and a dual X-ray absorptiometry exam. Among all patients included, 162 patients had a follow-up of Doppler-echocardiography exam and 103 patients a follow-up of MDCT exam to determine the annualized hemodynamic (i.e. annualized increase in peak aortic jet velocity [Vpeak]) and anatomic (i.e. annualized increase in aortic valve calcification [AVC]) progression rates of AS, respectively. According to the tertiles of femoral neck BMD, defined by sex-specific thresholds, there were no significant differences in baseline hemodynamic (lower tertile: 2.7 [2.3-3.0] vs. mid-tertile: 2.6 [2.4-3.0] vs. upper tertile: 2.7 [2.5-3.1] m/s, p=0.79) or anatomic (lower tertile: 690 [350-1280] vs. mid-tertile: 577 [253-926] vs. upper tertile: 636 [244-1103] AU, p=0.33) severity of AS (Figure Panel A and B). During a mean follow-up of 2.6±1.3 years, there were no significant differences in hemodynamic (lower tertile: +0.09 [0.02‒0.19] vs. mid-tertile: +0.05 [0.01‒0.18] vs. upper tertile: +0.07 [-0.01‒0.18] m/s/year, p=0.54) and anatomic (lower tertile: +95 [51-166] vs. mid-tertile: +72 [34-122] vs. upper tertile: +87 [29-203] AU, p=0.72) progression rate of AS (Figure Panel C and D). However, patients with osteoporosis (i.e. T-score ≤-2.5; n=8) presented a trend toward or significantly more severe AS at baseline (Vpeak: 2.9 [2.6-3.4] vs. 2.6 [2.4-3.0] m/s, p=0.13 / AVC: 1499 [682-1758] vs. 618 [275-1051] AU, p=0.03), and a trend for faster AS progression rate (Vpeak: +0.20 [0.07‒0.21] vs. +0.07 [0.01‒0.18] m/s/year, p=0.12 / AVC: +163 [68-258] vs. +87 [37-173] AU/year, p=0.58). In multivariable analyses, BMD was not associated with faster AS progression rate (all, p≥0.21), while osteoporosis was significantly associated with hemodynamic progression (p=0.01) but not with anatomic progression of AS (p=0.73), the latter likely related to the lower number of patients. Conclusion In this study, the absence of association between lower BMD and AS progression, may be at least related to the fact that there were very few patients with abnormally low BMD, likely reflecting the fact that the study population was optimally treated for osteoporosis

Impact of hypertension and renin-angiotensin system inhibitors in aortic stenosis

Background : Experimental studies revealed that renin–angiotensin system (RAS) could play a crucial role in the pathophysiology of aortic stenosis (AS). The objectives of this study were to examine (i) the impact of hypertension on AS progression and clinical events and (ii) the effect of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin-receptor blockers (ARBs). Materials and methods : In this observational study, we retrospectively analysed clinical and Doppler echocardiographic data prospectively collected in 338 patients with AS. Patients were separated into four groups: patients without hypertension and not treated by RAS medication (Ctrl group), patients with hypertension but not treated by RAS medication (HTN group), patients treated with ACEIs, and patients treated with ARBs. AS progression rate was assessed by the annualized increase in peak aortic jet velocity. Results : Compared with Ctrl group, patients in HTN group had faster stenosis progression (P = 0·01). Patients on ARBs had slower AS progression compared with Ctrl (trend P = 0·10) and HTN (P = 0·002) groups, whereas patients on ACEIs had similar progression rate compared with Ctrl group (P = NS) but lower compared with HTN group (P = 0·02). On multivariable analysis, compared with Ctrl group, HTN group was associated with faster AS progression rate (P = 0·002), whereas ARBs with slower progression (P = 0·0008). During a mean follow-up of 6·2 ± 2·4 years, HTN (hazard ratio [HR] = 2·45; P = 0·006) and ACEI (HR = 2·30; P = 0·01) groups were associated with a significant increase in all-cause mortality compared with Ctrl group, whereas ARB group (HR: 0·89; P = 0·80) not. In multivariable analysis, HTN and ACEI groups remained associated with increased mortality. Conclusions : Hypertension is associated with significantly faster stenosis progression and higher incidence of clinical events in patients with AS. ARBs but not ACEs were found to abolish the increased risk of mortality associated with hypertension