Stroke: valvular heart disease increased the risk of stroke and death

Clinical bottom line (level 2b)

  1. One in seven patients with valvular heart disease have a cerebrovascular event at 3.5 years.
  2. The risk is increased with
    • age
    • atrial fibrillation
    • severe aortic stenosis
  3. One in two are dead within 3.5 years.
  4. The risk increased with
    • age
    • cerebrovascular events
    • congestive heart failure
Petty et al: Stroke 2000; 31 : 2628-2635
Expires November 2003

The study

Retrospective cohort study with ?objective ?blinded outcomes, adjusted for confounding factors, not validated in an independent set of patients.

Setting: county, USA

729 patients (aged 13 to 107; mean 72, % male) with a moderate-to-severe mitral stenosis (3%), mitral regurgitation (72%), aortic stenosis (19%), aortic regurgitation (15%) or any combination (9%) diagnosed on 2-D echocardiography.

Excluded if
  • trivial or mild mitral or aortic stenosis or regurgitation
  • history of cerebrovascular events (stroke, TIA, amaurosis fugax)
  • living in county for 1 year or less


Factors studied:
  • age, sex, angina, duration and treatment of valvular heart disease, angina, myocardial infarction, hypertension, congestive heart failure, atrial fibrillation
  • age (10 yrs)
  • male with ischaemic heart disease
  • cerebrovascular events
  • congestive heart failure



    Cox proportional hazards model used to adjust for confounding factors.

    100% followed for median 3.5 years
    Outcomes studied:
  • cerebrovascular event stroke, TIA or amaurosis fugax
  • death

    The evidence

    outcome time to outcome number of patients/total number %
    (95% CI)    		 NNF
    (95% CI)
    cerebrovascular event 3.5 years 98/729 13.4%
    (11.0% to 15.9%)    		 7
    (6 to 9)
    death 3.5 years 356/729 48.8%
    (45.2% to 52.5%)    		 2
    (2 to 2)

    prognostic factor for
    death     		time to outcome adjusted RR
    (95% CI)    		 NNF+
    (95% CI)
    age (10 yrs) median 3.5 years 1.52
    (1.37 to 1.69)
    male with ischaemic heart disease median 3.5 years 1.90
    (1.33 to 2.70)     		6
    (3 to 16)
    cerebrovascular events median 3.5 years 4.34
    (2.38 to 7.95)     		2
    (1 to 4)
    congestive heart failure median 3.5 years 4.42
    (3.23 to 6.04)     		1
    (1 to 2)

    • Cerebrovascular events were significantly higher than corresponding age- and sex-adjusted rates for the community (SMR: 3.2; 95% CI: 2.6 to 3.8)
    • Mortality was significantly higher than age- or sex-adjusted mortality rates for the community (SMR: 2.5; 95% CI: 2.2 to 2.7)
    • Cerebrovascular events were independently associated
      • age
      • atrial fibrillation
      • severe aortic stenosis (v. moderate)

    Comments

    1. Patients died from congestive heart failure (25%), myocardial infarction (13%) and stroke (6%).

    Citation

    1. Petty GW, Khandheria BK, Whisnant JP, et al: predictors of cerebrovascular events and death among patients with valvular heart disease: a population-based study. Stroke 2000; 31 : 2628-2635
    Search Terms:
    Contributor: Chris Ball, November 2001
    Reviewer:

    Clinical Question.
    Patient valvular heart disease
    Intervention or Exposure severity and location of valvular disease
    Outcome stroke, death
    		•