View source for Aortic sclerosis natural history, complications and prognosis

{{Aortic sclerosis}}

{{CMG}}; {{AOEIC}} {{LG}}

==Overview==
Calcification of the aortic valve is common among the elderly population and shares epidemiologic and histopathologic similarities to [[atherosclerosis]].<ref name="pmid20185020">{{cite journal |author=Owens DS, Katz R, Takasu J, Kronmal R, Budoff MJ, O'Brien KD |title=Incidence and progression of aortic valve calcium in the Multi-ethnic Study of Atherosclerosis (MESA) |journal=[[The American Journal of Cardiology]] |volume=105 |issue=5 |pages=701–8 |year=2010 |month=March |pmid=20185020 |pmc=2829478 |doi=10.1016/j.amjcard.2009.10.071 |url=http://linkinghub.elsevier.com/retrieve/pii/S0002-9149(09)02766-0 |accessdate=2012-04-11}}</ref> Progressive thickening and calcification of the aortic valve subsequently causes left ventricular stiffness resulting in [[left ventricular outflow tract obstruction]], thereby leading to [[aortic stenosis]].<ref name="pmid10403851">{{cite journal |author=Otto CM, Lind BK, Kitzman DW, Gersh BJ, Siscovick DS |title=Association of aortic-valve sclerosis with cardiovascular mortality and morbidity in the elderly |journal=[[The New England Journal of Medicine]] |volume=341 |issue=3 |pages=142–7 |year=1999 |month=July |pmid=10403851 |doi=10.1056/NEJM199907153410302 |url=http://dx.doi.org/10.1056/NEJM199907153410302 |accessdate=2012-04-11}}</ref> Prognostically, it is known that [[aortic stenosis]] is clearly associated with adverse cardiovascular outcomes; however, it is unclear whether [[aortic sclerosis]] independently increases the risk of cardiovascular events or progression of [[aortic sclerosis]] to [[aortic stenosis]] increases the risk, including mortality.<ref name="pmid10403851">{{cite journal |author=Otto CM, Lind BK, Kitzman DW, Gersh BJ, Siscovick DS |title=Association of aortic-valve sclerosis with cardiovascular mortality and morbidity in the elderly |journal=[[The New England Journal of Medicine]] |volume=341 |issue=3 |pages=142–7 |year=1999 |month=July |pmid=10403851 |doi=10.1056/NEJM199907153410302 |url=http://dx.doi.org/10.1056/NEJM199907153410302 |accessdate=2012-04-11}}</ref>

==Natural History & Disease Progression==
===Progression to Aortic Stenosis===
*Echocardiographic indicators of progression of [[aortic sclerosis]] to [[aortic stenosis]] include:
:* Restricted leaflet mobility
:* Increased echogenicity suggestive of increase leaflet calcification
:* Increase in jet flow velocity across the valve

*Based on a '''''database study''''' from 1987 to 1993, that evaluated 2131 cases of aortic valve thickening with minimum 1-year echocardiographic follow-up, reported the development of [[aortic stenosis]] in '''15.9%''' cases, of which 10.5% developed [[mild AS]], 2.9% had [[moderate AS]] and 2.5% had [[severe AS]]. Thus, this study demonstrated the prevalence of benign aortic valve thickening with the progression to significant [[aortic stenosis]].<ref name="pmid12418948">{{cite journal |author=Cosmi JE, Kort S, Tunick PA, Rosenzweig BP, Freedberg RS, Katz ES, Applebaum RM, Kronzon I |title=The risk of the development of aortic stenosis in patients with "benign" aortic valve thickening |journal=[[Archives of Internal Medicine]] |volume=162 |issue=20 |pages=2345–7 |year=2002 |month=November |pmid=12418948 |doi= |url=http://archinte.ama-assn.org/cgi/pmidlookup?view=long&pmid=12418948 |accessdate=2012-04-11}}</ref><ref name="pmid12505585">{{cite journal |author=Faggiano P, Antonini-Canterin F, Erlicher A, Romeo C, Cervesato E, Pavan D, Piazza R, Huang G, Nicolosi GL |title=Progression of aortic valve sclerosis to aortic stenosis |journal=[[The American Journal of Cardiology]] |volume=91 |issue=1 |pages=99–101 |year=2003 |month=January |pmid=12505585 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0002914902030114 |accessdate=2012-04-11}}</ref>

*Another '''''large population-based cohort''''' reported an '''~9%''' of subjects with [[aortic sclerosis]] progressed to [[aortic stenosis]] over a 5-year echocardiographic follow-up. Additionally, no association was observed between [[C-reactive protein]] levels and the presence of calcific aortic-valve disease or incidental [[aortic stenosis]]. However, if [[C-reactive protein]] was present it was a poor predictor of subclinical calcific aortic-valve disease.<ref name="pmid17996566">{{cite journal |author=Novaro GM, Katz R, Aviles RJ, Gottdiener JS, Cushman M, Psaty BM, Otto CM, Griffin BP |title=Clinical factors, but not C-reactive protein, predict progression of calcific aortic-valve disease: the Cardiovascular Health Study |journal=[[Journal of the American College of Cardiology]] |volume=50 |issue=20 |pages=1992–8 |year=2007 |month=November |pmid=17996566 |doi=10.1016/j.jacc.2007.07.064 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(07)02703-9 |accessdate=2012-04-11}}</ref>

==Complication==
===Risk of Microembolism===
Spontaneous calcific embolization has been associated with calcific aortic valve disease;<ref name="pmid14173487">{{cite journal |author=HOLLEY KE, BAHN RC, MCGOON DC, MANKIN HT |title=SPONTANEOUS CALCIFIC EMBOLIZATION ASSOCIATED WITH CALCIFIC AORTIC STENOSIS |journal=[[Circulation]] |volume=27 |issue= |pages=197–202 |year=1963 |month=February |pmid=14173487 |doi= |url= |accessdate=2012-04-11}}</ref> however, Boon et al<ref name="pmid8623104">{{cite journal |author=Boon A, Lodder J, Cheriex E, Kessels F |title=Risk of stroke in a cohort of 815 patients with calcification of the aortic valve with or without stenosis |journal=[[Stroke; a Journal of Cerebral Circulation]] |volume=27 |issue=5 |pages=847–51 |year=1996 |month=May |pmid=8623104 |doi= |url=http://stroke.ahajournals.org/cgi/pmidlookup?view=long&pmid=8623104 |accessdate=2012-04-11}}</ref> and Kizer et al<ref name="pmid16254219">{{cite journal |author=Kizer JR, Wiebers DO, Whisnant JP, Galloway JM, Welty TK, Lee ET, Best LG, Resnick HE, Roman MJ, Devereux RB |title=Mitral annular calcification, aortic valve sclerosis, and incident stroke in adults free of clinical cardiovascular disease: the Strong Heart Study |journal=[[Stroke; a Journal of Cerebral Circulation]] |volume=36 |issue=12 |pages=2533–7 |year=2005 |month=December |pmid=16254219 |doi=10.1161/01.STR.0000190005.09442.ad |url=http://stroke.ahajournals.org/cgi/pmidlookup?view=long&pmid=16254219 |accessdate=2012-04-11}}</ref>, demonstrated no significant increase in the risk of [[stroke]] in [[aortic sclerosis]] patients with or without [[aortic stenosis]].<ref name="pmid10403851">{{cite journal |author=Otto CM, Lind BK, Kitzman DW, Gersh BJ, Siscovick DS |title=Association of aortic-valve sclerosis with cardiovascular mortality and morbidity in the elderly |journal=[[The New England Journal of Medicine]] |volume=341 |issue=3 |pages=142–7 |year=1999 |month=July |pmid=10403851 |doi=10.1056/NEJM199907153410302 |url=http://dx.doi.org/10.1056/NEJM199907153410302 |accessdate=2012-04-11}}</ref>

==Prognosis==
*Prognostically, it is known that [[aortic stenosis]] is clearly associated with adverse cardiovascular outcomes; however, it is unclear whether [[aortic sclerosis]] independently increases the risk of cardiovascular events or progression of [[aortic sclerosis]] to [[aortic stenosis]] increases the risk, including mortality.<ref name="pmid10403851">{{cite journal |author=Otto CM, Lind BK, Kitzman DW, Gersh BJ, Siscovick DS |title=Association of aortic-valve sclerosis with cardiovascular mortality and morbidity in the elderly |journal=[[The New England Journal of Medicine]] |volume=341 |issue=3 |pages=142–7 |year=1999 |month=July |pmid=10403851 |doi=10.1056/NEJM199907153410302 |url=http://dx.doi.org/10.1056/NEJM199907153410302 |accessdate=2012-04-11}}</ref> One of the possible explanation, could be that [[aortic sclerosis]] serves as a inflammatory marker for [[coronary artery disease]];<ref name="pmid14736432">{{cite journal |author=Chandra HR, Goldstein JA, Choudhary N, O'Neill CS, George PB, Gangasani SR, Cronin L, Marcovitz PA, Hauser AM, O'Neill WW |title=Adverse outcome in aortic sclerosis is associated with coronary artery disease and inflammation |journal=[[Journal of the American College of Cardiology]] |volume=43 |issue=2 |pages=169–75 |year=2004 |month=January |pmid=14736432 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0735109703014104 |accessdate=2012-04-11}}</ref><ref name="pmid14736433">{{cite journal |author=Otto CM |title=Why is aortic sclerosis associated with adverse clinical outcomes? |journal=[[Journal of the American College of Cardiology]] |volume=43 |issue=2 |pages=176–8 |year=2004 |month=January |pmid=14736433 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0735109703014098 |accessdate=2012-04-11}}</ref><ref name="pmid21679852">{{cite journal |author=Marincheva-Savcheva G, Subramanian S, Qadir S, Figueroa A, Truong Q, Vijayakumar J, Brady TJ, Hoffmann U, Tawakol A |title=Imaging of the aortic valve using fluorodeoxyglucose positron emission tomography increased valvular fluorodeoxyglucose uptake in aortic stenosis |journal=[[Journal of the American College of Cardiology]] |volume=57 |issue=25 |pages=2507–15 |year=2011 |month=June |pmid=21679852 |doi=10.1016/j.jacc.2010.12.046 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(11)01263-0 |accessdate=2012-04-11}}</ref> however, Novaro et al demonstrated no association between [[C-reactive protein]] levels and the presence of calcific aortic-valve disease or incidental [[aortic stenosis]].<ref name="pmid17996566">{{cite journal |author=Novaro GM, Katz R, Aviles RJ, Gottdiener JS, Cushman M, Psaty BM, Otto CM, Griffin BP |title=Clinical factors, but not C-reactive protein, predict progression of calcific aortic-valve disease: the Cardiovascular Health Study |journal=[[Journal of the American College of Cardiology]] |volume=50 |issue=20 |pages=1992–8 |year=2007 |month=November |pmid=17996566 |doi=10.1016/j.jacc.2007.07.064 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(07)02703-9 |accessdate=2012-04-11}}</ref>

*'''''Population-based prospective study''''', evaluated baseline [[transthoracic echocardiography|echocardiograms]] obtained from 5621 men and women 65 years of age or older, off which 70% had normal aortic valve, 29% had [[aortic sclerosis]] without [[Left ventricular outflow tract obstruction|outflow obstruction]] and only 2% had [[aortic stenosis]]. During a mean 5-year follow-up, a stepwise significant increase in mortality was observed in patients with increasing aortic-valve abnormality. Thus, the study concluded an '''~50% increase in the risk''' of death from cardiovascular causes and the risk of [[myocardial infarction]] in patients with [[aortic sclerosis]], even in the absence of hemodynamically significant [[LVOT|obstruction of left ventricular outflow]].<ref name="pmid10403851">{{cite journal |author=Otto CM, Lind BK, Kitzman DW, Gersh BJ, Siscovick DS |title=Association of aortic-valve sclerosis with cardiovascular mortality and morbidity in the elderly |journal=[[The New England Journal of Medicine]] |volume=341 |issue=3 |pages=142–7 |year=1999 |month=July |pmid=10403851 |doi=10.1056/NEJM199907153410302 |url=http://dx.doi.org/10.1056/NEJM199907153410302 |accessdate=2012-04-11}}</ref>

*Similar association between [[aortic sclerosis]] and the incidence of new coronary events were reported in multiple prospective studies<ref name="pmid10073870">{{cite journal |author=Aronow WS, Ahn C, Shirani J, Kronzon I |title=Comparison of frequency of new coronary events in older subjects with and without valvular aortic sclerosis |journal=[[The American Journal of Cardiology]] |volume=83 |issue=4 |pages=599–600, A8 |year=1999 |month=February |pmid=10073870 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0002-9149(98)00922-9 |accessdate=2012-04-11}}</ref><ref name="pmid15670554">{{cite journal |author=Taylor HA, Clark BL, Garrison RJ, Andrew ME, Han H, Fox ER, Arnett DK, Samdarshi T, Jones DW |title=Relation of aortic valve sclerosis to risk of coronary heart disease in African-Americans |journal=[[The American Journal of Cardiology]] |volume=95 |issue=3 |pages=401–4 |year=2005 |month=February |pmid=15670554 |doi=10.1016/j.amjcard.2004.09.043 |url=http://linkinghub.elsevier.com/retrieve/pii/S0002-9149(04)01611-X |accessdate=2012-04-11}}</ref> and was independent of co-existing cardiovascular disease or traditional cardiovascular risk factors.<ref name="pmid15619412">{{cite journal |author=Olsen MH, Wachtell K, Bella JN, Gerdts E, Palmieri V, Nieminen MS, Smith G, Ibsen H, Devereux RB |title=Aortic valve sclerosis relates to cardiovascular events in patients with hypertension (a LIFE substudy) |journal=[[The American Journal of Cardiology]] |volume=95 |issue=1 |pages=132–6 |year=2005 |month=January |pmid=15619412 |doi=10.1016/j.amjcard.2004.08.080 |url=http://linkinghub.elsevier.com/retrieve/pii/S0002-9149(04)01464-X |accessdate=2012-04-11}}</ref>

==References==
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