Author + information
- Received August 12, 2019
- Revision received October 23, 2019
- Accepted October 28, 2019
- Published online January 6, 2020.
- Li-Tan Yang, MDa,
- Patricia A. Pellikka, MDa,
- Maurice Enriquez-Sarano, MDa,
- Christopher G. Scott, MSb,
- Ratnasari Padang, MBBS, PhDa,
- Sunil V. Mankad, MDa,
- Hartzell V. Schaff, MDc and
- Hector I. Michelena, MDa,∗ (, )@michelenahector@MayoClinicCV
- aDepartment of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
- bDivision of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
- cDepartment of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
- ↵∗Address for correspondence:
Dr. Hector I. Michelena, Department of Cardiovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905.
Background The prognostic significance of diastolic blood pressure (DBP) and resting heart rate (RHR) in patients with hemodynamically significant aortic regurgitation (AR) is unknown.
Objectives This study sought to investigate the association of DBP and RHR with all-cause mortality in patients with AR.
Methods Consecutive patients with ≥ moderate to severe AR were retrospectively identified from 2006 to 2017. The association between all-cause mortality and routinely measured DBP and RHR was examined.
Results Of 820 patients (age 59 ± 17 years; 82% men) followed for 5.5 ± 3.5 years, 104 died under medical management, and 400 underwent aortic valve surgery (AVS). Age, symptoms, left ventricular ejection fraction (LVEF), LV end-systolic diameter-index (LVESDi), DBP, and RHR were univariable predictors of all-cause mortality (all p ≤ 0.002). When adjusted for demographics, comorbidities, and surgical triggers (symptoms, LVEF, and LVESDi), baseline DBP (adjusted-hazard ratio [HR]: 0.79 [95% confidence interval: 0.66 to 0.94] per 10 mm Hg increase, p = 0.009) and baseline RHR (adjusted HR: 1.23 [95% confidence interval: 1.03 to 1.45] per 10 beat per min [bpm] increase, p = 0.01) were independently associated with all-cause mortality. These associations persisted after adjustment for presence of hypertension, medications, time-dependent AVS, and using average DBP and RHR (all p ≤ 0.02). Compared with the general population, patients with AR exhibited excess mortality (relative risk of death >1), which rose steeply in inverse proportion (p nonlinearity = 0.002) to DBP starting at 70 mm Hg and peaking at 55 mm Hg and in direct proportion to RHR starting at 60 bpm.
Conclusions In patients with chronic hemodynamically significant AR, routinely measured DBP and RHR demonstrate a robust association with all-cause death, independent of demographics, comorbidities, guideline-based surgical triggers, presence of hypertension, and use of medications. Therefore, DBP and RHR should be integrated into comprehensive clinical decision-making for these patients.
This project is supported by a grant from Mayo Clinic Department of Cardiovascular Medicine. The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received August 12, 2019.
- Revision received October 23, 2019.
- Accepted October 28, 2019.
- 2020 American College of Cardiology Foundation
This article requires a subscription or purchase to view the full text. If you are a subscriber or member, click Login or the Subscribe link (top menu above) to access this article.