Valvular Heart Disease Prevalence, Progression, and Prognosis Among ARIC Study Participants – Cause for Concern

Shelbaya and colleagues report on the American College of Cardiology/American Heart Association (ACC/AHA) valvular heart disease (VHD) stage prevalence, progression, and association with incident cardiovascular diseases in late life among participants in the ARIC study (Atherosclerosis Risk in Communities).1 Their findings should raise concern for anyone dedicated to the care of patients with or at risk for VHD.

Researchers defined ACC/AHA stage for left-sided VHD (aortic stenosis, aortic regurgitation, mitral stenosis, and mitral regurgitation) for ARIC study participants at visits 5 (2011-2013, n = 6,118) and 7 (2018-2019, n = 2,896).

Prevalence – Among the 6,118 patients who completed visit 5 (mean age +/- SD of 76+/-5 years, 42% male, 22% self-identified Black race), the prevalence of Stage A VHD (“at risk”) was 39%, Stage B (“progressive”) was 17%, and Stage C/D (“severe”) was 1.1%. Severe aortic stenosis accounted for 80% of the overall Stage C/D VHD, aortic regurgitation was responsible for 62% of all Stage B VHD, and mitral regurgitation was responsible for 80% of all Stage A VHD. Mitral stenosis was the least common pathology in this elderly population. 0.7% had undergone previous valvular replacement or repair. VHD was present in 44% in Black men, 54% in Black women, 56% in White men, and 61% in White women. The prevalence of VHD increased with age. There was no VHD in 43% of patients.

Progression – During the 6.6 years (interquartile range, 6.1-7.0 years) between visit 5 and visit 7, the prevalence of no VHD decreased from 43% to 24% and Stage A VHD decreased from 39% to 31%. In contrast, the prevalence of Stage C/D VHD increased several-fold from 1.1% to 7.3% and valve replacement or repair doubled from 1.1% to 2.2%. Stage B VHD remained stable (17% to 16%). Similar increases in Stage C/D VHD were observed for aortic stenosis and mitral regurgitation. Older age was associated with greater increases in the prevalence of Stage C/D VHD.

Prognosis – At baseline during visit 5, greater VHD stage was associated with higher prevalence of cardiovascular risk factors, prevalent cardiovascular disease, as well as higher concentration of both NT-proBNP and high-sensitivity troponin T. Over a median follow-up of 6.5 years (interquartile range, 3.7-7.7 years), increasing VHD Stage was associated with greater risk of all-cause mortality, incident heart failure, incident atrial fibrillation, and incident coronary heart disease, but not with risk of incident stroke after adjusting for demographics and cardiovascular comorbidities. These graded risk associations were present even for Stage A VHD compared with no VHD and were observed for each valvular lesion individually. Polyvalvular disease was associated with a trend towards higher risk for the composite of death, heart failure, coronary heart disease, atrial fibrillation, or stroke.

This is the first study to report on the prevalence, progression, and prognosis of VHD on the basis of ACC/AHA stages. The findings are alarming. The majority of older adults have some degree of VHD. Both prevalence and severity increase with age. Importantly, having any degree of VHD, even stage A, correlates with adverse cardiovascular outcomes including mortality. The anticipated rise in the burden of VHD mandates a multipronged and multidisciplinary call to action.

References

  1. Shelbaya K, Claggett B, Dorbala P, Skali H, Solomon SD, Matsushita K, Konety S, Mosley TH, Shah AM. Stages of Valvular Heart Disease Among Older Adults in the Community: The Atherosclerosis Risk in Communities Study. Circulation [Internet]. 2022;Available from: https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.122.061396