Aortic valve sclerosis in acute coronary syndrome patients

e-Herz: Original article Herz 2013 DOI 10.1007/s00059-013-3936-6 Received: 23 June 2013 Revised: 17 July 2013 Accepted: 26 July 2013 © Urban & Vogel 2013 e-Herz L. Korkmaz · E. Pelit · H. Bektas · M.T. Ağaç · H. Erkan · I. Gurbak · Ş Çelik Department of Cardiology, Ahi Evren Cardiovascular and Thoracic Surgery Training and Research Hospital, Trabzon Aortic valve sclerosis in acute coronary syndrome patients Potential value in predicting coronary artery lesion complexity Identifying acute coronary syndrome (ACS) patients with higher cardiovascular risk is important both in estimating the prognosis and triage of these patients. Current risk scores are based on clinical, biochemical, and/or electrocardiographic variables [1, 2]. Beyond the known clinical and laboratory predictors, baseline angiographic markers of disease burden, calcification, lesion severity, and morphological characteristics have important independent predictive value for 30-day and 1-year ischemic outcomes in ACS patients [3]. The SYNTAX score (SxScore) is a comprehensive angiographic scoring system that is derived solely from the coronary anatomy and lesion characteristics [4, 5, 6]. Aortic valve sclerosis (AVS) is defined by echocardiography as thickening and calcification of the normal trileaflet aortic valve without obstruction to the left ventricular outflow and considered as a marker of systemic atherosclerosis. Atherosclerotic burden may be related to the coronary artery lesion complexity [7]. AVS may reflect the atherosclerotic process, and the relationship between AVS and coronary atherosclerosis has been demonstrated [8, 9, 10]. But no study has been performed to investigate the association between AVS and coronary artery lesion complexity as determined using the Sx- Score in ACS patients. The main aim of the present study was to investigate this relationship. Material and methods Patients In all, 164 consecutive patients with a first time diagnosis of non-ST segment elevation ACS undergoing coronary angiograTab. 1 phy and intervention were enrolled. ACS was diagnosed when an elevation of troponin T level (>0.01 ng/ml in any sample during admission) and/or a typical creatine kinase-MB fraction (CKMB) curve occurred, with or without ST/T changes in the ECG, in the absence of any other demonstrable cause for chest pain. None of the patients had any previous cardiovascular event or coronary revascularization. Clinical and demographic characteristics of patients (n=164) with and without AVS Variables Age, years Hypertension, n (%) Diabetes, n (%) Dyslipidemia, n (%) Smoking, n (%) SxScore BMI, kg/m2 LDL, mg/dl HDL, mg/dl Triglycerides, mg/dl Cholesterol, mg/dl Coronary angiography lesions – LMCA, n – LAD, n – LCX, n – RCA, n 65±12 73 (44) 25 (15) 18 (11) 65 (39) 14±7 29±3 137±38 43±11 147±70 209±44 4 52 88 86 BMI body mass index, LDL low density cholesterol, HDL high density cholesterol, SxScore SYNTAX score, LMCA left main coronary artery, LAD left anterior descending, LCX left circumflex artery, RCA right coronary artery. Herz 2013 | 1 e-Herz: Original article Tab. 2 Clinical and demographic characteristics of patients with and without AVS Age, years Hypertension, n (%) Diabetes, n (%) Dyslipidemia, n (%) Smoking, n (%) Presence of AVS BMI (kg/m2) LDL(mg/dl) HDL(mg/dl) Triglycerides (mg/dl) Cholesterol (mg/dl) SxScore ≤15 n=100 62±11 41 (41) 14 (14) 34 (34) 41 (41) 15 (15) 29±5 135±37 44±13 148±78 207±45 SxScore >15 n=64 68±15 32 (50) 11 (17) 19 (30) 24 (38) 25 (40) 30±4 138±36 42±12 147±68 211±44 p 0.03 0.58 0.09 0.29 0.14 0.007 0.21 0.25 0.29 0.14 0.55 AVS aortic valve sclerosis, BMI body mass index, LDL low density cholesterol, HDL high density cholesterol. 40,0 Syntax Score 30,0 20,0 P: 0.02 10,0 0,0 AVS (-) AVS (+) Fig. 1 9 SYNTAX score in patients with and without AVS. AVS aortic valve sclerosis 90 No AVS 80 AVS 70 60 50 40 30 20 SxScore ≤ 15 Herz 2013 Coronary angiography was performed using the Judkins technique and analyzed by two experienced observers. Each angiogram was analyzed independently by two experienced interventional cardiologists who were blinded to the clinical data. In cases of disagreement, the decision of a third person was obtained and the final decision was made by consensus. Each coronary lesion producing 50% diameter stenosis in vessels with a diameter of 1.5 mm was scored separately and added together to provide the overall SxScore, which was calculated prospectively using the SxScore algorithm [6]. SxScore > 15 Fig. 2 8 Number of AVS patients with low and high SxScore. SxScore Syntax score, AVS aortic valve sclerosis 2 | Coronary angiography and SxScore Assessment of cardiovascular risk factors 10 0 Patients with a history of MI, valvular disease, acute or chronic heart failure, cardiomyopathy, systolic dysfunction, ejection fraction <50%, or renal, liver and neoplastic diseases were excluded. In addition, patients with aortic stenosis (transaortic flow velocity >2.5 m/s), rheumatic valvular disease, prosthetic valves, bicuspid aortic valves, congenital heart disease, or bacterial endocarditis were excluded. Patients with ST elevation on the admission ECG were excluded. Patients were also excluded when the evolution of the ECG showed the development of a new left bundle branch block or new Q waves. Other exclusion criteria were known or suspected infectious or inflammatory conditions or need of urgent coronary angiography and intervention. AVS was defined by echocardiography as thickening and calcification of the normal trileaflet aortic valve without obstruction to the left ventricular outflow. Echocardiography examination was performed in all patients before coronary angiography by a single operator (EP) who was blinded to the patients’ clinical and laboratory variables. In addition to questions about the symptoms of CHD, PAD, and stroke, data on cardiovascular risk factors, diabetes mellitus, arterial hypertension, and smoking habits were obtained. Patients were considered to be hypertensive if they had a Abstract · Zusammenfassung systolic blood pressure (BP) >140 mmHg and/or diastolic BP >90 mmHg or were taking antihypertensive drugs. Subjects with fasting glucose ≥126 mg/dl and/or on treatment were considered as having diabetes. Smoking was defined as “current smokers” or “non-smokers”. Hypercholesterolemia was defined as total cholesterol >200 mg/dl or taking medications. Statistical analysis Continuous variables were expressed as mean ± standard deviation (SD) and categorical variables were expressed as percentage. An analysis of normality of the continuous variables was performed with the Kolmogorov–Smirnov test. A comparison of the categorical variables between the groups was performed using a χ2 test. Continuous variables were compared using unpaired t-test and Mann– Whitney U test. Pearson and Spearman correlation tests were used for continuous variables. The χ2 analysis was used for categorical variables. Linear regression analysis was performed in order to identify independent determinants for the SxScore. A p<0.05 was considered significant. Statistical analysis was carried out using SPSS 14.0 statistical software. Results Demographics and clinical characteristics of subjects are listed in . Tab. 1. There was significantly higher SxScore in subjects with AVS than those without AVS (18±6 vs 12±5, p=0.02; . Fig. 1). There was statistically positive correlation between SxScore and AVS (r=0.28, p=0.001), and age (r=0.29, p=0.001). Patients were divided into two groups according to their SxScores in order to find independent determinants of a high SxScore (. Tab. 2). Patients with a high SxScore (SxScore >15) had greater numbers of AVS compared to those who had a low SxScore (SxScore ≤15) [25 (40%) patients with a high SxScore versus 15 (15%) patients with a low SxScore, p=0.007] (. Fig. 2). In the univariate analysis, age (p=0.03) and presence of AVS (p=0.007) were significantly associated with higher SxScore. Logistic regression analysis dem- Herz 2013 · [jvn]:[afp]–[alp] © Urban & Vogel 2013 DOI 10.1007/s00059-013-3936-6 L. Korkmaz · E. Pelit · H. Bektas · M.T. Ağaç · H. Erkan · I. Gurbak · Ş Çelik Aortic valve sclerosis in acute coronary syndrome patients. Potential value in predicting coronary artery lesion complexity Abstract Objective. The purpose of the present study was to investigate the relation between aortic valve sclerosis (AVS) and coronary artery lesion complexity as assessed using the SYNTAX score (SxScore) in acute coronary syndrome (ACS) patients. Patients and methods. A total of 164 patients with a first time diagnosis of acute coronary syndrome were consecutively enrolled. AVS was defined by echocardiography as thickening and calcification of the normal trileaflet aortic valve without obstruction to the left ventricular outflow. The SxScore was calculated using dedicated computer software. Results. There were significantly higher SxScores in subjects with AVS than those with- out AVS (18±6 vs 12±5, p=0.02). In the univariate analysis, age (p=0.03) and presence of AVS (p=0.007) were significantly associated with higher SxScores. Logistic regression analysis demonstrated AVS [95% confidence interval (CI) 0.17–0.86, p=0.017] and age (95% CI 1.01–1.21, p=0.028) as independent determinants of higher SxScores. Conclusion. Aortic valve sclerosis was significantly and independently associated with a high SxScore in acute coronary syndrome patients. Keywords Aortic valve · Acute coronary syndrome · SYNTAX score · Ischemia · Risk assessment Aortenklappensklerose beim akuten Koronarsyndrom. Mögliche Relevanz für die Prädiktion der Komplexizität von Koronararterienläsionen Zusammenfassung Ziel. Untersucht werden sollte der Zusammenhang zwischen einer Aortenklappensklerose (AVS) und der Komplexizität von Koronararterienläsionen (Assessment über den SYNTAX- bzw. SX-Score) bei akutem Koronarsyndrom (ACS). Patienten und Methoden. Insgesamt 164 konsekutive Patienten mit der Erstdiagnose ACS wurden in die Studie aufgenommen. Eine AVS war definiert als echokardiographisch nachgewiesene Verdickung und Verkalkung einer normalen dreisegligen Aortenklappe ohne Obstruktion der linksventrikulären Ausflussbahn. Der SX-Score wurde mit geeigneter Software berechnet. Ergebnisse. Bei Patienten mit AVS waren die SX-Scores signifikant höher als bei denje- onstrated AVS [95% confidence interval (CI) 0.17–0.86, p=0.017] and age (95% CI: 1.01–1.21, p=0.028) as independent determinants of a higher SxScore. Discussion Increased rates of complex coronary artery lesions were found in ACS patients with AVS. In addition, we demonstrated significant and independent association between AVS and SxScore. nigen ohne AVS (18±6 vs. 12±5, p=0,02). In der univariaten Analyse waren Alter (p=0,03) und AVS (p=0,007) statistisch signifikant mit höheren SX-Scores assoziiert. In der logistischen Regressionsanalyse erwiesen sich AVS [95%-Konfidenzintervall (KI) 0,17– 0,86, p=0,017] und Alter (95%-KI 1,01–1,21, p=0,028) als unabhängige Determinanten höherer SX-Scores. Fazit. Bei ACS-Patienten war eine AVS statistisch signifikant und unabhängig mit einem hohen SX-Score assoziiert. Schlüsselwörter Aortenklappe · Akutes Koronarsyndrom · SYNTAX-Score · Ischämie · Risikoassessment The SxScore is a comprehensive angiographic scoring system that is derived solely from the coronary anatomy and lesion characteristics. The SxScore is used in the risk stratification of patients with STEMI undergoing primary PCI and is a useful tool that provides additional risk stratification to known risk factors of longterm mortality and MACE [11]. The clinical significance of SxScore has also been shown in non-ST segment elevation ACS patients [5]. The poorer prognosis and Herz 2013 | 3 e-Herz: Original article increased MACE in patients with higher SxScores may be explained by differences in clinical, angiographic, and procedural characteristics. For clinical characteristics, patients with higher SxScore were older and more commonly had previous MI, diabetes, or renal dysfunction [5, 12, 13]. These patients also presented with higher pulse rates, cardiogenic shock, and anterior STEMI. As for procedural and angiographic characteristics, implanted stents were longer, more likely to involve bifurcations and had increased rate of thrombosis in patients with higher SxScore [11, 13]. Procedure failure with thrombolysis in myocardial infarction (TIMI) 0/1 flow, low myocardial brush grade (MBG) and high corrected TIMI frame count (cTFC) were more common in the highest tertile SxScore [10, 12]. In addition, there was a significant positive association between SxScore and periprocedural myocardial necrosis during PCI which is associated with worse outcomes, including death [14, 15, 16]. Recent studies have suggested that AVS is a manifestation of the atherosclerotic process and documented overlap in the clinical factors traditionally associated with AVS and atherosclerosis [17]. AVS was found to be a marker of significant obstructive CAD in patients with chest pain [9]. In patients with an inconclusive treadmill exercise test, presence of AVS on echocardiography was demonstrated as a good predictor of CAD [18]. AVS group had a higher positive rate of coronary angiography and a higher incidence rate of multivessel CAD than the non-AVS group [19]. Furthermore, echocardiographic detection of AVS in patients undergoing diagnostic coronary angiography can provide information on the extent of coronary atherosclerosis as determined by Gensini score [7]. Our study has several limitations. First of all, study population is relatively small and patients with previous CAD or having any coronary revascularization were excluded. Moreover, only those patients who underwent coronary catheterization and subsequently revascularization were included. Therefore, our study can not represent the entire ACS population. Another limitation is that our study design was cross sectional; thus, it does not allow 4 | Herz 2013 conclusions regarding pathophysiological mechanisms. Conclusion Although the origin of the association between AVS and SxScore remains to be explained, this study is the first to report a significant association between AVS and SxScore in a small cohort of patients with ACS. Attention to AVS on echocardiography may enable physicians to detect higher risk patients with ACS. Corresponding address L. Korkmaz Department of Cardiology, Ahi Evren Cardiovascular and Thoracic Surgery Training and Research Hospital Trabzon Turkey [email protected] Compliance with ethical guidelines Conflict of interest. L. Korkmaz, E. Pelit, H. Bektas, M.T. Ağaç, H. Erkan, I. Gurbak, and Ş. Çelik state that there are no conflicts of interest. All studies on humans described in the present manuscript were carried out with the approval of the responsible ethics committee and in accordance with national law and the Helsinki Declaration of 1975 (in its current, revised form). Informed consent was obtained from all patients included in studies. References 1. 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