Valvular heart disease in older adults: seeking an ounce of prevention.

Abstract

In 1848, Dr A. Whyte Barclay presented the results of his survey of the prevalence of valvular heart disease (VHD) from 419 autopsies occurring over a 2-year period at the St George’s Hospital in the UK. VHD was noted in 19%, with rheumatic disease and associated infectious endocarditis frequently noted, particularly among the younger patients. However, he also noted evidence of ‘atheromatous disease either on the valves themselves or in their immediate vicinity’ in 27%, with a markedly higher prevalence among older patients. Today, degenerative disease accounts for the majority of haemodynamically significant VHD in industrialized countries. In the USA, older adults 65 years of age are projected to account for 20% of the population by 2030. Moderate or severe VHD affects 2.5% of the US population, with a prevalence that increases steeply with age, affecting up to 12% of persons 75 years old. Significant VHD remains linked to worse prognosis, and is associated with a 35–75% higher risk of death compared with those without significant valvular disease. In this issue of the journal, baseline findings from the OxVALVE Population Cohort Study (OxVALVE-PCS) confirm the substantial burden of VHD in elderly persons. This prospective cohort study, designed to investigate the epidemiology of VHD in persons 65 years of age, recruited participants from five primary care medical centres in Oxfordshire, UK who then underwent echocardiography and clinical assessments. By combining the prevalence of diagnosed VHD (using National Health Service diagnostic codes) with new VHD detected by echocardiography, these investigators estimated a prevalence of moderate or severe VHD of 11.3% in their sample. From this analysis, it is unclear how many of these persons met clinical indications for valve intervention, given the importance both of patient symptoms and of the distinction between moderate and severe dysfunction in this therapeutic determination. However, findings from the Euro Heart Survey on VHD clearly demonstrate that a sizable proportion of elderly persons with significant VHD are candidates for intervention. The pool of older patients who are valve intervention candidates is expected to continue to grow with the expanding percutaneous options for VHD. Indeed, a recent metaanalysis and simulation study estimated that 290 000 persons >75 years of age in Europe and North America are candidates for transcatheter aortic valve replacement (TAVR) with 27 000 new candidates annually. Developing options for percutaneous mitral valve and tricuspid valve repair and further refinement of TAVR techniques will expand treatment options for severe VHD, and the number of elderly candidates for intervention. While these advances will demand refinement of patient selection for these procedures, they have—and will continue to—benefit our patients with severe VHD requiring therapy. However, OxVALVE-PCS also provides comprehensive estimates of the prevalence of lesser degrees of valvular dysfunction in older adults. They noted similar age-related increase in the prevalence of mild valve dysfunction, concordant with previous community-based samples for both regurgitant and stenotic VHD. The relatively high prevalence of mild VHD in these epidemiological studies emphasizes the progressive nature of VHD, whereby a subset of persons progress from a milder to a more severe degrees of valve dysfunction over time. The framework of VHD stages was adopted by the most recent American Heart Association/American College of Cardiology Valvular Heart Disease guidelines to emphasize the progressive nature of VHD. Stage A VHD defines an at-risk group based on morphological abnormalities of the valves, myocardium, and vessels. Stage B is characterized by progressive VHD based on the haemodynamic consequences of the lesion, while Stage C encompasses asymptomatic severe disease and Stage D symptomatic severe disease. While ageing is an important risk factor for progression through these stages, epidemiological and mechanistic studies also suggest an active pathological process. Higher blood pressure, worse renal function, and valvular calcification have been identified as risk factors for valvular regurgitation. Calcific stenotic VHD, and aortic sclerosis/stenosis in

DOI: 10.1093/eurheartj/ehw354

Cite this paper

@article{Shah2016ValvularHD, title={Valvular heart disease in older adults: seeking an ounce of prevention.}, author={Amil M . Shah and Scott Solomon}, journal={European heart journal}, year={2016}, volume={37 47}, pages={3523-3524} }