Aortic Valve Calcium in Relation to Subclinical Cardiac Dysfunction and Risk of Heart Failure

Abstract

Background: The link between (mild) aortic valve calcium (AVC) with subclinical cardiac dysfunction and with risk of heart failure (HF) remains unclear. This research aims to determine the association of computed tomography-assessed AVC with echocardiographic measurements of cardiac dysfunction, and with HF in the general population. Methods: We included 2348 participants of the Rotterdam Study cohort (mean age 68.5 years, 52% women), who had AVC measurement between 2003 and 2006, and without history of HF at baseline. Linear regression models were used to explore relationship between AVC and echocardiographic measures at baseline. Participants were followed until December 2016. Fine and Gray subdistribution hazard models were used to assess the association of AVC with incident HF, accounting for death as a competing risk. Results: The presence of AVC or greater AVC were associated with larger mean left ventricular mass and larger mean left atrial size. In particular, AVC ≥800 showed a strong association (body surface area indexed left ventricular mass, β coefficient: 22.01; left atrium diameter, β coefficient: 0.17). During a median of 9.8 years follow-up, 182 incident HF cases were identified. After accounting for death events and adjusting for cardiovascular risk factors, one-unit larger log (AVC+1) was associated with a 10% increase in the subdistribution hazard of HF (subdistribution hazard ratio, 1.10 [95% CI, 1.03–1.18]), but the presence of AVC was not significantly associated with HF risk in fully adjusted models. Compared with the AVC=0, AVC between 300 and 799 (subdistribution hazard ratio, 2.36 [95% CI, 1.32–4.19]) and AVC ≥800 (subdistribution hazard ratio, 2.54 [95% CI, 1.31–4.90]) were associated with a high risk of HF. Conclusions: Presence and high levels of AVC were associated with markers of left ventricular structure, independent of traditional cardiovascular risk factors. Larger computed tomography-assessed AVC is an indicative of increased risk for the development of HF.

Unlocking the Secrets of Subclinical Calcific Aortic Valve Disease and Heart Failure

“…15 While the presence of AVC was associated with worse left ventricular ejection fraction, the practical clinical implications of the difference between 65.6±7% and 63.4±8% are unclear. 1 Moreover, the authors acknowledge limitations that may impact insight into pathophysiology and mechanism, including lack of information regarding left ventricular function at the time of overt HF and regarding HF phenotype, HFpEF versus HFrEF.…”

“…When investigators control for history of atrial fibrillation, the association between AVC and incident HF remains significant, supporting that a thromboembolic mechanism is less likely. 1 Challenges adjudicating atrial fibrillation and difficulty identifying subclinical atrial fibrillation may prevent full assessment of the impact of this arrhythmia. Recent and growing data on the association between other supraventricular tachyarrhythmias and cryptogenic cerebrovascular events suggestive of thromboembolic phenomena raise the question of additional confounding that must be kept in mind.…”

“…Unlocking the Secrets of Subclinical Calcific Aortic Valve Disease and Heart Failure Sheila Sharma , ScM; Alan R. Morrison , MD, PhD I n this issue of Circulation: Cardiovascular Imaging, Zhu et al 1 set out to assess the relationship between subclinical calcific aortic valve disease (CAVD) and measures of cardiac structure and function followed by the relationship between CAVD and incident heart failure (HF). The study makes use of the well-characterized Rotterdam Study cohort, developed in the 1990s with the purpose of defining etiology and natural history of various chronic diseases including CAVD.…”

“…While prior work on AVC in this area focused on cardiovascular events, the critical novel finding that Zhu et al 1 identify is the association of AVC with the outcome of incident heart failure. Through a combination of careful echocardiographic measures and sensitivity analyses, the authors pry away at potential plausible mechanisms that may be at the heart of this association.…”

“…Possibilities for this lack of association relative to prior studies in the field may reflect the overall study population, which had a lower prevalence of tobacco smoking, diabetes mellitus, and coronary artery disease. 1,6,8 An additional limitation, which may influence the power to assess the relationship between AVC and mortality, includes the small numbers of patients with moderate to severe AVC, AS, or CHD.…”