Aortic Stenosis: Changing Disease Concepts
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Aortic stenosis (AS) occurs in almost 10% of adults over age 80 years with a mortality about 50% at 2 years unless outflowobstruction is relieved by aortic valve replacement (AVR). Development of AS is associated with anatomic, clinical and geneticrisk factors including a bicuspid valve in 50%; clinical factors that include older age, hypertension, smoking, diabetes andelevated serum lipoprotein(a) [Lp(a)] levels; and genetic factors such as a polymorphism in the Lp(a) locus. Early stages of AS arecharacterized by focal areas of leaflet thickening and calcification. The rate of hemodynamic progression is variable but eventualsevere AS is inevitable once even mild valve obstruction is present. There is no specific medical therapy to prevent leaflet calcification. Basic principles of medical therapy for asymptomatic AS are patient education, periodic echocardiographic and clinicalmonitoring, standard cardiac risk factor evaluation and modification and treatment of hypertension or other comorbid conditions. When severe AS is present, a careful evaluation for symptoms is needed, often with an exercise test to document symptom statusand cardiac reserve. In symptomatic patients with severe AS, AVR improves survival and relieves symptoms. In asymptomaticpatients with severe AS, AVR also is appropriate if ejection fraction is < 50%, disease progression is rapid or AS is very severe(aortic velocity > 5 m/s). The choice of surgical or transcatheter AVR depends on the estimated surgical risk plus other factorssuch as frailty, other organ system disease and procedural specific impediments.
Abstract
Aortic stenosis (AS) occurs in almost 10% of adults over age 80 years with a mortality about 50% at 2 years unless outflowobstruction is relieved by aortic valve replacement (AVR). Development of AS is associated with anatomic, clinical and geneticrisk factors including a bicuspid valve in 50%; clinical factors that include older age, hypertension, smoking, diabetes andelevated serum lipoprotein(a) [Lp(a)] levels; and genetic factors such as a polymorphism in the Lp(a) locus. Early stages of AS arecharacterized by focal areas of leaflet thickening and calcification. The rate of hemodynamic progression is variable but eventualsevere AS is inevitable once even mild valve obstruction is present. There is no specific medical therapy to prevent leaflet calcification. Basic principles of medical therapy for asymptomatic AS are patient education, periodic echocardiographic and clinicalmonitoring, standard cardiac risk factor evaluation and modification and treatment of hypertension or other comorbid conditions. When severe AS is present, a careful evaluation for symptoms is needed, often with an exercise test to document symptom statusand cardiac reserve. In symptomatic patients with severe AS, AVR improves survival and relieves symptoms. In asymptomaticpatients with severe AS, AVR also is appropriate if ejection fraction is < 50%, disease progression is rapid or AS is very severe(aortic velocity > 5 m/s). The choice of surgical or transcatheter AVR depends on the estimated surgical risk plus other factorssuch as frailty, other organ system disease and procedural specific impediments.
참고문헌 (49)
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