Predictors of Cerebrovascular Events and Death Among Patients With Valvular Heart Disease

Abstract

Background and Purpose-There is little population-based information on cerebrovascular events and survival among valvular heart disease patients. We used the Kaplan-Meier product-limit method and the Cox proportional hazards model to determine rates and predictors of cerebrovascular events and death among valve disease patients. Methods-This population-based historical cohort study in Olmsted County, Minnesota, reviewed residents with a first echocardiographic diagnosis of mitral stenosis (nϭ19), mitral regurgitation (nϭ528), aortic stenosis (nϭ140), and aortic regurgitation (nϭ106) between 1985 and 1992. Results-During 2694 person-years of follow-up, 98 patients developed cerebrovascular events and 356 died. Compared with expected numbers, these observations are significantly elevated, with standardized morbidity ratio of 3.2 (95% CI, 2.6 to 3.8) and 2.5 (95% CI, 2.2 to 2.7), respectively. Independent predictors of cerebrovascular events were age, atrial fibrillation, and severe aortic stenosis. The risk ratio of severe aortic stenosis was 3.5 (95% CI, 1.4 to 8.6), with atrial fibrillation conferring greater risk at younger age. Predictors of death were age, sex, cerebrovascular events, ischemic heart disease, and congestive heart failure, the greatest risk being among those with both congestive heart failure and cerebrovascular events (risk ratioϭ8.8; 95% CI, 5.8 to 13.4). Valve disease type and severity were not independent determinants of death. Conclusions-The risk of cerebrovascular events and death among patients with valve disease remains high. Age, atrial fibrillation, and severe aortic stenosis are independent predictors of cerebrovascular events, and age, sex, cerebrovascular events, congestive heart failure, and ischemic heart disease are independent predictors of death in these patients.

Apixaban in Comparison With Warfarin in Patients With Atrial Fibrillation and Valvular Heart Disease

“…18 Among patients with valvular heart disease, age, atrial fibrillation, and aortic stenosis are independent predictors of cerebrovascular events. 5 In the ARISTOTLE study, detailed echocardiographic information on valvular heart disease severity was not collected, and classification of valvular lesion and severity relied on clinical data collected in the case report forms. Patients with clinically significant (moderate to severe) mitral stenosis and those with mechanical prosthetic heart valves were excluded; however, patients with any other form of valvular heart disease including mild mitral stenosis, mitral regurgitation, aortic stenosis or regurgitation, tricuspid valve disease, and previous valve surgery were included.…”

Shortening the NIH Stroke Scale for Use in the Prehospital Setting

“…Five hundred bootstrap iterations were performed with the items retained by the forward and backward stepwise logistic regression models; relative importance was approximated by the percentage of logistic models when PՅ0.10 for the individual item. 13 …”

2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

“…With the absence of RCTs that demonstrated the efficacy of antibiotic prophylaxis to prevent infective endocarditis (IE), the practice of antibiotic prophylaxis has been questioned by national and international medical societies� [11][12][13][14] Moreover, there is not universal agreement on which patient populations are at higher risk of developing IE than the general population� Protection from endocarditis in patients undergoing high-risk procedures is not guaranteed� A prospective study demonstrated that prophylaxis given to patients for what is typically considered a high-risk dental procedure reduced but did not eliminate the incidence of bacteremia� 15 A 2013 Cochrane Database systematic review of antibiotic prophylaxis of IE in dentistry concluded that there is no evidence to determine whether antibiotic prophylaxis is effective or ineffective, highlighting the need for further study of this longstanding clinical dilemma� 13 Epidemiological data conflict with regard to incidence of IE after adoption of more limited prophylaxis, as recommended by the AHA and European Society of Cardiology, [16][17][18][19][20] and no prophylaxis, as recommended by the U�K� NICE (National Institute for Health and Clinical Excellence) guidelines� 21 Some studies indicate no increase in incidence of endocarditis with limited or no prophylaxis, whereas others suggest that IE cases have increased with adoption of the new guidelines� [16][17][18][19][20][21][22] The consensus of the writing group is that antibiotic prophylaxis is reasonable for the subset of patients at increased risk of developing IE and at high risk of experiencing adverse outcomes from IE� There is no evidence for IE prophylaxis in gastrointestinal procedures or genitourinary procedures, absent known active infection�…”