The canadian women’s heart health alliance ATLAS on the epidemiology, diagnosis, and management of cardiovascular disease in women - chapter 2 : scope of the problem

Background This Atlas chapter summarizes the epidemiology of cardiovascular disease (CVD) in women in Canada, discusses sex and gender disparities, and examines the intersectionality between sex and other factors that play a prominent role in CVD outcomes in women, including gender, indigenous identity, ethnic variation, disability, and socioeconomic status. Methods CVD is the leading cause of premature death in Canadian women. Coronary artery disease, including myocardial infarction, and followed by stroke, accounts for the majority of CVD-related deaths in Canadian women. The majority of emergency department visits and hospitalizations by women are due to coronary artery disease, heart failure, and stroke. The effect of traditional cardiovascular risk factors and their association with increasing cardiovascular morbidity is unique in this group. Results Indigenous women in Canada experience increased CVD, linked to colonization and subsequent social, economic, and political challenges. Women from particular racial and ethnic backgrounds (ie, South Asian, Afro-Caribbean, Hispanic, and Chinese North American women) have greater CVD risk factors, and CVD risk in East Asian women increases with duration of stay in Canada. Conclusions Canadians living in northern, rural, remote, and on-reserve residences experience greater CVD morbidity, mortality, and risk factors. An increase in CVD risk among Canadian women has been linked with a background of lower socioeconomic status, and women with disabilities have an increased risk of adverse cardiac events.Contexte Ce chapitre de l'Atlas condense l'épidémiologie des maladies cardiovasculaires (MCV) chez les femmes au Canada, aborde les disparités entre les sexes et les genres, et examine l'interrelation entre le sexe et d'autres facteurs qui jouent un rôle important dans l'émergence des MCV chez les femmes, notamment le genre, l'identité autochtone, les variations ethniques, le handicap et le statut socio-économique. Méthodes Les MCV sont la principale cause de décès prématuré chez les femmes canadiennes. Les maladies coronariennes, y compris l'infarctus du myocarde, suivies des accidents vasculaires cérébraux, sont à l'origine de la majorité des décès liés aux MCV chez les femmes canadiennes. La majorité des visites aux urgences et des hospitalisations des femmes sont dues à des maladies coronariennes, des insuffisances cardiaques et des accidents vasculaires cérébraux. L'effet des facteurs de risque cardiovasculaire traditionnels et leur association avec l'augmentation de la morbidité cardiovasculaire est unique dans ce groupe. Résultats Les femmes autochtones du Canada connaissent un accroissement des maladies cardiovasculaires, liée à la colonisation et aux défis sociaux, économiques et politiques qui en découlent. Les femmes d'origines raciales et ethniques spécifiques (par exemple les femmes sud-asiatiques, afro-caribéennes, hispaniques et chinoises d'Amérique du Nord) présentent des facteurs de risque de MCV plus importants, et le risque de MCV chez les femmes d'Asie de l'Est augmente avec la durée de leur séjour au Canada. Conclusions Les canadiens qui vivent dans les régions nordiques, rurales, éloignées et dans les réserves présentent une morbidité, une mortalité et des facteurs de risque de MCV plus élevés. L'augmentation du risque de MCV chez les femmes canadiennes a été associée à un statut socio-économique plus bas, et les femmes handicapées ont un risque accru de survenue d'événements cardiaques indésirables

Management of paradoxical low-flow, low-gradient aortic stenosis : need for an integrated approach, including assessment of symptoms, hypertension, and stenosis severity

In 2007, we reported that a substantial proportion of patients with severe aortic stenosis may have a low flow (LF) (i.e., reduced stroke volume), and thus, often have a low transvalvular pressure gradient (LG), despite a preserved left ventricular ejection fraction (LVEF) (1). The 2014 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines (2) classified this “paradoxical” LF/LG entity as a D3 stage of aortic stenosis, which is defined as an aortic valve area (AVA) of 50%, and a stroke volume index (SVi) of <35 ml/m2. Previous studies 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 and 13 reported that patients with paradoxical LF/LG aortic stenosis have worse outcomes than patients with moderate aortic stenosis or with severe aortic stenosis and a high-gradient (HG) and that their outcomes improve with aortic valve replacement (AVR). Accordingly, the 2014 ACC/AHA guidelines included a Class IIa (Level of Evidence: C) recommendation for AVR in these patients: “AVR is reasonable in symptomatic patients who have low-flow, low-gradient severe AS who are normotensive and have a LVEF =50% if clinical, hemodynamic, and anatomic data support valve obstruction as the most likely cause of symptoms” (2). The main findings of the retrospective study by Tribouilloy et al. (14) published in this issue of the Journal were: 1) patients with LF/LG and preserved LVEF have similar outcomes as patients with moderate aortic stenosis or with severe aortic stenosis and a HG; and 2) AVR does not improve these patients’ outcomes. The investigators should be commended for providing important data on the challenging subset of patients with paradoxical LF/LG aortic stenosis

Assessment of low-flow, low-gradient aortic stenosis : multimodality imaging is the key to success

In patients with aortic stenosis (AS), a low-flow state may occur with reduced LV ejection fraction (LVEF) (i.e., classic low flow) or with preserved LVEF (i.e., paradoxical low flow) and it is often associated with low gradient because the gradient is highly flow-dependent. Low-flow, low-gradient (LF-LG) AS is a frequent clinical entity generally associated with worse outcomes. A multimodality imaging approach, including comprehensive resting echocardiography, dobutamine stress echocardiography (DSE), and multidetector computed tomography (MDCT), is the key to successful management of patients with LF-LG AS, who represent a highly challenging subset from both a diagnostic and a therapeutic standpoint. DSE and quantification of aortic valve calcification by MDCT provide important information that is crucial to differentiate true-severe from pseudo-severe AS and therefore select the most appropriate therapy (i.e., AVR vs. medical). The assessment of LV flow reserve by DSE is useful to stratify the operative risk and guide decision making between surgical and transcatheter AVR. Other imaging biomarkers, such as the global LV longitudinal strain measured during DSE or the amount of myocardial fibrosis assessed by cardiac magnetic resonance imaging, may provide incremental information for risk stratification and therapeutic management in LF-LG AS, but additional studies are needed to validate and refine these emerging biomarkers further

Multimodality imaging for discordant low-gradient aortic stenosis : assessing the valve and the myocardium

Aortic stenosis (AS) is a disease of the valve and the myocardium. A correct assessment of the valve disease severity is key to define the need for aortic valve replacement (AVR), but a better understanding of the myocardial consequences of the increased afterload is paramount to optimize the timing of the intervention. Transthoracic echocardiography remains the cornerstone of AS assessment, as it is universally available, and it allows a comprehensive structural and hemodynamic evaluation of both the aortic valve and the rest of the heart. However, it may not be sufficient as a significant proportion of patients with severe AS presents with discordant grading (i.e., an AVA ≤1 cm2 and a mean gradien

Comparison between cardiovascular magnetic resonance and transthoracic doppler echocardiography for the estimation of effective orifice area in aortic stenosis

<p>Abstract</p> <p>Background</p> <p>The effective orifice area (EOA) estimated by transthoracic Doppler echocardiography (TTE) via the continuity equation is commonly used to determine the severity of aortic stenosis (AS). However, there are often discrepancies between TTE-derived EOA and invasive indices of stenosis, thus raising uncertainty about actual definite severity. Cardiovascular magnetic resonance (CMR) has emerged as an alternative method for non-invasive estimation of valve EOA. The objective of this study was to assess the concordance between TTE and CMR for the estimation of valve EOA.</p> <p>Methods and results</p> <p>31 patients with mild to severe AS (EOA range: 0.72 to 1.73 cm²) and seven (7) healthy control subjects with normal transvalvular flow rate underwent TTE and velocity-encoded CMR. Valve EOA was calculated by the continuity equation. CMR revealed that the left ventricular outflow tract (LVOT) cross-section is typically oval and not circular. As a consequence, TTE underestimated the LVOT cross-sectional area (A_LVOT, 3.84 ± 0.80 cm²) compared to CMR (4.78 ± 1.05 cm²). On the other hand, TTE overestimated the LVOT velocity-time integral (VTI_LVOT: 21 ± 4 vs. 15 ± 4 cm). Good concordance was observed between TTE and CMR for estimation of aortic jet VTI (61 ± 22 vs. 57 ± 20 cm). Overall, there was a good correlation and concordance between TTE-derived and CMR-derived EOAs (1.53 ± 0.67 vs. 1.59 ± 0.73 cm², r = 0.92, bias = 0.06 ± 0.29 cm²). The intra- and inter- observer variability of TTE-derived EOA was 5 ± 5% and 9 ± 5%, respectively, compared to 2 ± 1% and 7 ± 5% for CMR-derived EOA.</p> <p>Conclusion</p> <p>Underestimation of A_LVOTby TTE is compensated by overestimation of VTI_LVOT, thereby resulting in a good concordance between TTE and CMR for estimation of aortic valve EOA. CMR was associated with less intra- and inter- observer measurement variability compared to TTE. CMR provides a non-invasive and reliable alternative to Doppler-echocardiography for the quantification of AS severity.</p

Case report : posterior thoracic window in the presence of pleural effusion in critical care medicine : one more chance to image the aortic valve

Good quality echocardiographic images in the setting of critical care medicine may be difficult to obtain for many reasons. We present a case of an 85-year-old woman with acute pulmonary edema and pleural effusion, where transthoracic bedside echocardiographic examination raised a suspicion for significant aortic valve disease. However, given the orthopneic decubitus of the patients, the quality of images was poor. To increase the accuracy of diagnosis, a posterior thoracic view through the pleural effusion in the sitting position was used. This view allowed the diagnosis of mixed aortic valve disease (aortic stenosis and regurgitation) and the quantification of valve disease through multiparametric criteria as recommended by current guidelines. The posterior thoracic view, when feasible, may provide a useful option in the assessment of cardiac structures and further diagnostic information in technically difficult echocardiographic examinations

Comparison of early surgical or transcatheter aortic valve replacement versus conservative management in low-flow, low-gradient aortic stenosis sing Inverse Probability of Treatment Weighting: Results From the TOPAS Prospective Observational Cohort Study

BACKGROUND: No randomized comparison of early (ie, ≤3 months) aortic valve replacement (AVR) versus conservative management or of transcatheter AVR (TAVR) versus surgical AVR has been conducted in patients with low-flow, low-gradient (LFLG) aortic stenosis (AS). METHODS AND RESULTS: A total of 481 consecutive patients (75±10 years; 71% men) with LFLG AS (aortic valve area ≤0.6 cm2/ m2 and mean gradient <40 mm Hg), 72% with classic LFLG and 28% with paradoxical LFLG, were prospectively recruited in the multicenter TOPAS (True or Pseudo Severe Aortic Stenosis) study. True-severe AS or pseudo-severe AS was adjudicated by flow-independent criteria. During follow-up (median [IQR] 36 [11–60] months), 220 patients died. Using inverse probability of treatment weighting to address the bias of nonrandom treatment assignment, early AVR (n=272) was associated with a major overall survival benefit (hazard ratio [HR], 0.34 [95% CI, 0.24–0.50]; P<0.001). This benefit was observed in patients with true-severe AS but also with pseudo-severe AS (HR, 0.38 [95% CI, 0.18–0.81]; P=0.01), and in classic (HR, 0.33 [95% CI, 0.22–0.49]; P<0.001) and paradoxical LFLG AS (HR, 0.42 [95% CI, 0.20–0.92]; P=0.03). Compared with conservative management in the conventional multivariate model, trans femoral TAVR was associated with the best survival (HR, 0.23 [95% CI, 0.12–0.43]; P<0.001), followed by surgical AVR (HR, 0.36 [95% CI, 0.23–0.56]; P<0.001) and alternative-access TAVR (HR, 0.51 [95% CI, 0.31–0.82]; P=0.007). In the inverse probability of treatment weighting model, trans femoral TAVR appeared to be superior to surgical AVR (HR [95% CI] 0.28 [0.11–0.72]; P=0.008) with regard to survival. CONCLUSIONS: In this large prospective observational study of LFLG AS, early AVR appeared to confer a major survival benefit in both classic and paradoxical LFLG AS. This benefit seems to extend to the subgroup with pseudo-severe AS. Our findings suggest that TAVR using femoral access might be the best strategy in these patients

The marvel of percutaneous cardiovascular devices in the elderly

Thanks to minimally invasive procedures, frail and elderly patients can also benefit from innovative technologies. More than 14 million implanted pacemakers deliver impulses to the heart muscle to regulate the heart rate (treating bradycardias and blocks). The first human implantation of defibrillators was performed in early 2000. The defibrillator detects cardiac arrhythmias and corrects them by delivering electric shocks. The ongoing development of minimally invasive technologies has also broadened the scope of treatment for elderly patients with vascular stenosis and aneurysmal disease as well as other complex vascular pathologies. The nonsurgical cardiac valve replacement represents one of the most recent and exciting developments, demonstrating the feasibility of replacing a heart valve by way of placement through an intra-arterial or trans-ventricular sheath. Percutaneous devices are particularly well suited for the elderly as the surgical risks of minimally invasive surgery are considerably less as compared to open surgery, leading to a shorter hospital stay, a faster recovery, and improved quality of life