ORIGINAL ARTICLE

Prevalence of coronary atherosclerosis in patients with aortic valve replacement

J.P. Ottervanger, K Thomas, T.H. Sie, M.M.P. Haalebos, F. Zijlstra

Background. Because of a high prevalence of coronary artery disease in patients with aortic valve disease, coronary angiography is recommended before aortic valve replacement. However, during the last three decades, a decline in mortality due to coronary heart disease has been observed in the general population in both Western Europe and the United States. It is unknown whether preoperative angiography is still mandatory in all patients. Aim. To assess the prevalence of angiographically defined coronary artery disease in patients with aortic valve replacement and trends during a tenyear period. Methods. We performed a retrospective crosssectional study ofpatients undergoing aortic valve replacement between 1988 and 1998 in our institution. Patients with a history of coronary artery disease and patients younger than 25 years were exduded. Coronary atherosderosis was defined as one or more coronary artery luminal stenosis of 50% or more on preoperative coronary angiography. Results. During the study period 1339 patients had aortic valve replacement in our institution, data on 1322 (98%) were available for analysis. Previous coronary artery disease was documented in 124 patients (10%). After exdusion of 17 patients (no angiography), data on a total of 1181 patients were analysed. Coronary atherosclerosis was present in 472 patients (40%) on preoperative coronary angiography. Several well-known risk factors of ischaemic heart disease were associated with coronary atherosclerosis. The prevalence of angioJ.P. Ottervanger. K. Thomas. T.H. Sle. M.M.P. Haalebos. F. ZlJlstra. Department of Cardiology and Cardiothoracic Surgery, Isala Clinics, Weezenlanden Hospital, Zwolle. Address for correspondence: Dr. F. Zijistra E-mail: [email protected]

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graphically defined coronary atherosderosis varied between 30% and 50% per year. There was, however, no significant trend during the study period. Multivariate analyses, to adjust for potential differences in risk factors during the observation period, did not change this condusion. Conclusions. The prevalence of angiographically defined coronary artery disease in patients scheduled for aortic valve replacement is still high. From 1988 to 1998, no significant change was observed in angiographic measures of coronary atherosderosis in patients with aortic valve replacement. Therefore, it is advised to perform coronary angiography before aortic valve surgery. (Neth Heart J 2002;10:176-80.) Key words: coronary heart disease, epidemiology, angiography, aortic valve replacement ecause patients with aortic valve disease have a high

Bprevalence of coronary artery disease" 2 it is advised to perform pre-operative coronary angiography before aortic valve replacement in every patient.3 However, many reports on the prevalence of coronary artery disease in patients with aortic valve replacement are from older studies.47 Although cardiovascular diseases are still the major cause ofdeath in most developed and developing countries, a decline in mortality due to coronary heart disease has been observed both in Western Europe8-10 and the United States"",12 during the last three decades. So, it is uncertain whether preoperative angiography in every patient scheduled for aortic valve replacement is still justified. Since all patients with aortic valve disease have routine coronary angiography before surgery in our hospital, even in the absence of angina pectoris, we had the opportunity to assess the prevalence of angiographically defined coronary artery disease over a long

time period. Methods Data were retrospectively collected over a ten-year period from all consecutive patients undergoing aortic Netherlands Heart Journal, Volume 10, Number 4, April 2002

Prevalence of coronary atherosclerosis in patients with aortic valve replacement

valvular replacement in the Weezenlanden Hospital, Zwolle, the Netherlands, between 1988 and 1998. Patients who had a history of coronary artery disease and patients younger than 25 years were excluded. In general, coronary angiography was performed by the Judkins technique via the right femoral artery, either at the Weezenlanden hospital or at a referral hospital. All angiograms were interpreted at the Weezenlanden hospital before surgery by at least two experienced observers, as part of a formalised decisionmaking procedure, that is used to recommend conservative, medical therapy and/or surgery for patients with valvular heart disease. The degree of coronary artery stenosis was estimated by visual inspection of coronary angiograms in multiple projections, as the obstructed proportion of each vessel, given as a percentage of the vessel's diameter. Significant coronary atherosclerosis was defined as one or more coronary artery lumenal stenosis of 50% or greater on angiography, since this is the degree of stenosis thought necessary to compromise blood flow during a hyperaemic response.'3" 4 Quantitative coronary angiography analyses were not routinely performed. A history of coronary artery disease was defined as a documented acute myocardial infarction before angiography. An acute myocardial infarction was defined as enzyme-confirmed myocardial necrosis (creatine kinase at least twice upper normal values, or creatine kinase MB fraction/total creatine kinase more than 10%). A history of chest pain alone was insufficient for the diagnosis of coronary artery disease, since patients with aortic stenosis may present with chest pain. Hypertension was defined as a systolic blood pressure of at least 160 mmHg and/or a diastolic blood pressure of at least 95 mmHg, or when patients were taking antihypertensive medication for the indication hypertension before surgery. Patients were classified as being diabetic only if antidiabetic drug therapy had been initiated prior to aortic valve replacement. Patients were classified as having hypercholesterolaemia if total cholesterol was higher than 6.5 mmol/L or if they were using medication for hypercholesterolaemia. Hospital mortality was defined as mortality within 28 days after surgery.

Table 1. Characteristics of 1181 patients with aortic heart valve replacement.

Characteristic (unit) Male Mean age (years) Smoking Hypercholesterolaemia# Mean cholesterol (mmol/l)# Diabetes mellitus Hypertension Hospital mortality *

Number or mean 712 (60%) 65 ± 11 309 (26%) 351 (31%) 6.0 ± 1.3 102 (9%) 358 (30%) 30 (2.5%)

no data were available on 66 patients (6%)

Results

During the study period, 1339 patients had an aortic valve replacement in our institution. Data on a total of 1322 patients (98%) were available for analysis. Of these patients, 17 were excluded because coronary angiography was not performed or because they were younger than 25 years. Previous coronary artery disease was documented in 124 patients (10%). The baseline characteristics of the remaining 1181 patients are summarised in table 1. Of the study population, 66% were men and 13% were older than 75 years. Females were older than males (67±10 versus 63±11, p

Prevalence of coronary atherosclerosis in patients with aortic valve replacement.

Because of a high prevalence of coronary artery disease in patients with aortic valve disease, coronary angiography is recommended before aortic valve...
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