Prevalence of Findings in Routine Abdominal Ultrasound in Patients with Systemic Autoimmune Rheumatic Diseases and Their Impact on Therapeutic Decision Making

Patients with systemic autoimmune rheumatic diseases (SARD) often receive abdominal ultrasound examinations to screen for organ involvement; yet, the spectrum of findings and their clinical relevance are poorly understood. We conducted a retrospective chart review of inpatients from a rheumatological referral centre with an abdominal ultrasound between 1 January2006 and 31 December 2015, examining 1092 SARD patients with a total of 1695 inpatient stays. The mean age was 55.1 years (range: 17–90 years, SD: 15.8), and the mean disease duration was 6.4 years (range: 0.0–52.8 years, SD: 9.1). A total of 87.5% of the patients were female. The most frequent ultrasound findings were hepatic steatosis (in 26.8% of all patients), splenomegaly (15.2% of all patients), pancreatic lipomatosis (14.3% of all patients) and aortic sclerosis (13.9% of all patients). Based on glucocorticoid and disease-modifying antirheumatic drug use, we identified cases where immuno-modulatory medication was escalated; there was an association between therapy escalation and the findings of hepatomegaly and pleural effusion (as tested via Fisher’s exact test). In patients with several examinations during the defined time span (n = 318), we found ultrasound findings to change, especially findings of hepatomegaly, pleural effusion and splenomegaly. When justifying decisions regarding the further treatment of a patient in the discharge letter, abdominal ultrasound results were rarely discussed. Abdominal ultrasound rarely yielded disease-specific or treatment-changing results.

Survival of people with valvular heart disease in a large, English community-based cohort study

ObjectiveValvular heart disease (VHD) is present in half the population aged >65 years but is usually mild and of uncertain importance. We investigated the association between VHD and its phenotypes with all-cause and cause-specific mortality.MethodsThe OxVALVE (Oxford Valvular Heart Disease) population cohort study screened 4009 participants aged >65 years to establish the presence and severity of VHD. We linked data to a national mortality registry and undertook detailed outcome analysis.ResultsMortality data were available for 3511 participants, of whom 361 (10.3%) died (median 6.49 years follow-up). Most had some form of valve abnormality (n=2645, 70.2%). In adjusted analyses, neither mild VHD (prevalence 44.9%) nor clinically significant VHD (moderate or severe stenosis or regurgitation; 5.2%) was associated with increased all-cause mortality (HR 1.20, 95% CI 0.96 to 1.51 and HR 1.47, 95% CI 0.94 to 2.31, respectively). Conversely, advanced aortic sclerosis (prevalence 2.25%) and advanced mitral annular calcification (MAC, 1.31%) were associated with an increased risk of death (HR 2.05, 95% CI 1.28 to 3.30 and HR 2.51, 95% CI 1.41 to 4.49, respectively). Mortality was highest for people with both clinically significant VHD and advanced aortic sclerosis or MAC (HR 4.38, 95% CI 1.99 to 9.67).ConclusionsAdvanced aortic sclerosis or MAC is associated with a worse outcome, particularly for patients with significant VHD, but also in the absence of other VHD. Older patients with mild VHD can be reassured about their prognosis. The absence of an association between significant VHD and mortality may reflect its relatively low prevalence in our cohort.

Aortic valve stenosis

Aortic valve stenosis (AS) is the most prevalent valvular heart disease and is increasingly diagnosed in high-income countries due to an ageing population but also to more widely available diagnostic tools. The prevalence of AS is estimated at ~0.5% in the general population, ~2–3% in the population over 65 years old. This disease starts with mild fibrosis and calcification and thickening of the aortic valve leaflets without obstruction of blood flow, which is termed aortic sclerosis, and evolves over the years to severe calcification with impaired leaflet mobility and significant obstruction to blood flow, i.e. AS. The clinical presentation includes the spectrum from asymptomatic patients with different grades (mild, moderate, severe) of AS severity to symptomatic patients with severe AS who may present with preserved or already depressed left ventricular (LV) function and/or reduced transvalvular flow. Accurate assessment of the AS anatomic and haemodynamic severity as well as the extent of cardiac damage associated with AS are crucial for the therapeutic management of patients with AS. Doppler-echocardiography is the method of choice providing a comprehensive non-invasive diagnostic work-up of these patients.

Ventricular Remodeling in Aortic Sclerosis

Background and aims. Aortic sclerosis associates an increased risk of cardiovascular morbidity and mortality. Recent studies suggest that aortic sclerosis is able to produce ventricular remodeling through inflammatory, non-hemodynamic mechanisms. Our study aims to evaluate the correlation between ventricular remodeling and aortic sclerosis severity.Method. 68 patients with aortic sclerosis without other signifficant associated valvulopathies were examined clinically, biologically and echocardiographic. In 20 patients, we quantiffied the severity of aortic valve calciffication using the backscatter ecographic technique, in parasternal long and short axis view. Backscatter values obtained at the valvular level were calibrated to the blood and pericardium backscatter values.Results. In the 68 patients group, transvalvular aortic velocity correlates with left ventricular mass (p =0.031), which in turn incline to augment with increasing calciffication severity assessed by backscatter. Calciffication severity assessed by backscatter corellates with transvalvular aortic velocity in parasternal long axis view (p =0.039 for blood calibrated backscatter, p =0.029 for pericardium calibrated backscatter), and tends to augment with increasing transvalvular aortic velocity in parasternal short axis view. Patients with normal ventricular geometry incline to have lower aortic transvalvular velocities and a lower degree of calciffication (evaluated by backscatter) compared to patients with ventricular remodeling.Conclusions. Aortic sclerosis is not benign, and may lead, in time, to left ventricular remodeling. With the progression of valvular calciffications in aortic sclerosis patients, the prevalence of ventricular remodeling tends to increase.

Aortic Valvular Disease in Elderly Subjects with Heterozygous Familial Hypercholesterolemia: Impact of Lipid-Lowering Therapy

Hypercholesterolemia and statins are risk factors for aortic stenosis (AS) and vascular calcification, respectively. Whether heterozygous subjects with familial hypercholesterolemia (HeFH) treated with statins are at risk of AS is unknown. We study the prevalence of AS, aortic valve calcification (AoVC), and aortic sclerosis (ASc) in elderly subjects with HeFH in a prolonged statin treatment. Case-control study, cases were adults ≥65 years of age with a genetic diagnosis of HeFH, LDLc >220 mg/dl, and statin treatment ≥5 years. Controls were relatives of HeFH patients, with LDLc <190 mg/dl. Participants underwent a cardiac ultrasound for aortic valve analysis. We studied 205 subjects, 112 HeFH and 93 controls, with mean age 71.8(6.5) years and 70.0(7.3) years, respectively. HeHF, with respect to controls, presented greater gradients of aortic transvalvular pressure, 7.4(7.3) mmHg versus 5.0(2.8) mmHg, and maximum aortic velocity, 1.7(0.7) m/s versus 1.5(0.4) m/s, and lower aortic valve opening area, 2.0(0.7) cm2 versus 2.4(0.6) cm2 (all p < 0.05). AoVC and ASc were also more prevalent in HeFH (p < 0.05 between groups). Moderate/severe AS prevalence was higher among HeFH: 7.1% versus 1.1% (age- and sex-adjusted odds ratio (OR) 8.33, p = 0.03). Independent risk factors for aortic valve disease in HeFH were age and LDLc before treatment. The number of years under statin treatment was not associated with any aortic valve measurement. Subjects ≥65 years with HeFH in prolonged statin treatment show more aortic valvular disease and higher frequency of AS than controls. Life-long elevated LDLc exposure, rather than time of exposure to statins, explains this higher risk.

Assessment of diastolic function in patients with aortic valve diseases

Background: Valvular heart disease (VHD) are prevalent and impose significant impact on heart function. Diastolic Dysfunction (DD) is less appreciated than Systolic Dysfunction (SD). The aim of this study was to assess the Diastolic Function (DF) in patients with Aortic Valve (AV) diseases as risk factors predisposing to DD.Methods: Cross-section study that involved 34 patients with AV diseases and other 10 controls. All patients are assessed for diastolic dysfunction by transthoracic echo Doppler study. M-mode echocardiography was used to measure cardiac dimensions and wall thickness. LV mass was measured on echocardiogram at rest.Results: Among the 34-patients, 19 (55.8%) of them were male patients and 15(44.2%) of them were female patients. The data showed that there were 12 patients with Aortic Stenosis (AS), eight patients with AORTIC regurgitation (AR), six patients with Aortic Sclerosis (ASCL) and 8 patients with combined AR-AS. Around third of the patients (35.3%) had Grade II DD followed by grade I and Grade III. However, around 14.7 % didn’t have any dysfunction. Overall, there was 77% of the patients with AV diseases.Conclusions: Author concluded that Aortic Valve diseases is significantly related to- the development of diastolic dysfunction and the DD is influenced by severity of AV diseases.

Valve area and the risk of overestimating aortic stenosis

ObjectiveTo obtain reference values of aortic valve area (AVA) in a large population and to infer the risk of overestimating aortic stenosis (AS) when focusing on flow-corrected indices of severity.MethodsWe prospectively measured indices of AS in all consecutive echocardiograms performed in a large referral cardiac imaging laboratory for 1 year. We specifically analysed the distribution of AVA, indexed AVA and velocity ratio (Vratio) in patients with and without AS, the latter defined as the coexistence of valvular outflow obstruction (Vmax ≥2.5 m/s) and morphological findings of valve degeneration.Results16 156 echocardiograms were analysed, 14 669 of which did not show valvular obstruction (peak jet velocity <2.5 m/s). In the latter group, AVA was 2.6±0.7 cm2 in 8190 studies with normal valves and 2.3±0.7 cm2 in 6479 studies with aortic sclerosis (AScl). There was a relatively wide overlap between values of AVA, indexed AVA and velocity ratio between studies of patients with AScl and AS. Values of AVA ≤1.0 cm2 were found in 0.5% of studies with normal valves and 1.8% of studies with AScl. These proportions were 3.1% and 9.3% for AVA ≤1.5 cm2, respectively. Vratio ≤0.25 were found in 0.1% of patients without obstruction. Risk factors for a small AVA in patients without obstruction were AScl, female sex, small body surface area, low ejection fraction and mitral regurgitation.ConclusionsNormal values of continuity-equation derived AVA are smaller than previously considered. AVA values below cutoffs of moderate or severe AS can be found in patients without the disease. Flow-corrected indices may overestimate AS in patients with low gradients, particularly in the presence of well-identified risk factors.