Diastolic Blood Pressure and Heart Rate Are Independently Associated With Mortality in Chronic Aortic Regurgitation

• Published in: Journal of the American College of Cardiology 2020-01, Vol.75 (1), p.29-39
• Main Authors: Yang, Li-Tan, Pellikka, Patricia A., Enriquez-Sarano, Maurice, Scott, Christopher G., Padang, Ratnasari, Mankad, Sunil V., Schaff, Hartzell V., Michelena, Hector I.
• Format: Article
• Language: English
• Subjects: Adult; Aged; aortic regurgitation; Aortic valve; Aortic Valve Insufficiency - diagnostic imaging; Aortic Valve Insufficiency - mortality; Aortic Valve Insufficiency - physiopathology; Blood pressure; Blood Pressure - physiology; Cardiac arrhythmia; Cardiology; Cardiovascular disease; Chronic Disease; Clinical decision making; Comorbidity; Confidence intervals; Coronary vessels; Decision making; Demographics; Demography; Diameters; diastolic blood pressure; Female; Heart rate; Heart Rate - physiology; Humans; Hypertension; Identification methods; Male; Medical records; Middle Aged; Mortality; Mortality - trends; Nonlinear systems; Patients; Regurgitation; Retrospective Studies; Risk Factors; Studies; Surgery; Time dependence; Ventricle
• ISSN: 0735-1097; 1558-3597
• DOI: 10.1016/j.jacc.2019.10.047

The prognostic significance of diastolic blood pressure (DBP) and resting heart rate (RHR) in patients with hemodynamically significant aortic regurgitation (AR) is unknown. This study sought to investigate the association of DBP and RHR with all-cause mortality in patients with AR. 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. 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. 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. [Display omitted]