Aortic Stenosis and Other Important Topics to Be Featured in a New Series on Cardiovascular Issues in the Older Adult
Cardiac disease remains the number one cause of morbidity and mortality in the elderly. Advances in the diagnosis and treatment of a variety of cardiac problems have led to an improvement in both the quality and quantity of life for many persons. That said, all too often there is a delay in the older person receiving appropriate treatment. While this may result from a delay in the older person seeking medical care himself or herself, at times important signs and symptoms may be confused as being due to other age-prevalent problems, and early treatment is not sought. A bias against treatment due to advanced age may also result in suboptimal and inappropriate medical care. This issue of Clinical Geriatrics begins a series devoted to “Cardiovascular Issues in the Older Adult.” The first article for this series is titled “Aortic Stenosis: A Focused Review on the Elderly.” It will be followed in future issues by other articles that will discuss such topics as the chronic diagnosis and treatment o c orthostatic hypotension, devices for heart rhythm disorders, management of hypertension, management of heart failure, atrial fibrillation, and peripheral arterial disease.
Calcific or degenerative aortic valve disease is the most common valvular problem found in the elderly. In a study of over 500 randomly selected men and women age 75 to 86 years, the prevalence of at least moderate aortic stenosis was reported to be 5% based on Doppler echocardiography.1 In addition, 1% to 2% were noted to have severe aortic stenosis, a figure that rises to almost 6% for those over age 86. Women are affected more frequently than men.1,2 Similar prevalences have been reported from referral centers and nursing home populations, with an even higher prevalence reported in those over 90 years of age.3
The two most common causes of aortic stenosis severe enough to require surgery are calcification of congenital bicuspid aortic valves and the degenerative calcification of tricuspid aortic valves. Among patients over age 70 who have aortic stenosis, approximately 60% are identified with a tricuspid valve and 40% with a bicuspid valve. In patients between the ages of 50 and 70 years, approximately two-thirds have been found to have a bicuspid valve and one-third a tricuspid valve; rarely will a patient be identified with a unicuspid valve.
While we are well aware of the significance of having a severely stenotic aortic valve and the poor prognosis that late associated findings such as syncope and heart failure imply, the diagnosis of aortic stenosis can usually be made early in its course on physical examination and later confirmed and characterized using an echocardiogram. In this way, the disease progression can be monitored and interventions taken in a proactive manner when cardiovascular function becomes severely compromised. The question of who to operate on, however, is often not as easy as simply measuring flow velocity across the valve and the area of the valve surface itself. Function, quality of life, comorbidities, and personal preference may all influence who is a surgical candidate and who is not. In any case, treatment options have greatly increased over the years, and I have seen successful surgeries in individuals who are in their late 90s on many occasions, to the surprise of many who felt that age itself should be a contraindication. We have, indeed, come a long way in our ability to identify and treat valvular heart disease and other cardiovascular illness in recent times, and I can only imagine what the future holds.
I remember my uncle having rudimentary surgery for an aortic valve that was severely stenotic in the early 1960s. He did not have a valve replacement, as these were not yet readily available at that time, but rather endured a “scraping” of the calcium from the valve opening itself. He was told that this was a temporary fix and that the calcification would return at a later date and would require a repeat procedure. He lived with a daily fear and dread of needing to have this procedure repeated, something he described as a painful and frightening experience. When the time came to have the repeat surgery, he refused, knowing full well that his decision would hasten his death. My uncle died a few months later, only a brief time before valvular replacement surgery became more widespread and acceptable.
Timing is everything, as they say; we are fortunate to live in an era of healthcare that, in many cases, can offer simple solutions to complex problems on a daily basis, treatment that may easily be taken for granted. Today, aortic stenosis is a readily treatable problem and one that no longer has to be feared, but it does need to be identified! While I could go on, I suggest that you read the article on aortic stenosis in this issue of the Journal and future articles in the Cardiovascular Issues in the Older Adult series as they are published. As always, we look forward to your comments.
Dr. Gambert is Professor of Medicine and Associate Chair for Clinical Program Development, Co-Director, Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Maryland School of Medicine, Director, Geriatric Medicine, University of Maryland Medical Center and R Adams Cowley Shock Trauma Center, and Professor Medicine, Division of Gerontology and Geriatric Medicine, Johns Hopkins University School of Medicine, Baltimore, MD. References 1. Lindroos M, Kupari M, Heikkilä J, Tilvis R. Prevalence of aortic valve abnormalities in the elderly: an echocardiographic study of a random population sample. J Am Coll Cardiol. 1993;21(5):1220-1225.
2. Aronow WS, Kronzon I. Prevalence and severity of valvular aortic stenosis determined by Doppler echocardiography and its association with echocardiographic and electrocardiographic left ventricular hypertrophy and physical signs of aortic stenosis in elderly patients. Am J Cardiol. 1991;67(8):776-777.
3. Tunick PA, Freedberg RS, Kronzon I. Cardiac findings in the very elderly: analysis of echocardiography in fifty-eight nonagenarians. Gerontology. 1990;36(4):206-211.
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