AORTIC SCLEROSIS MAY SIGNAL INCREASED CARDIOVASCULAR RISK

For many years, doctors often believed that signs of early aortic valve disease were harmless provided that the valve was functioning normally. Aortic valve sclerosis, or calcification of the aortic valve, refers to a build up of calcium deposits on the leaflets of the valve. This oftentimes will result in a heart murmur, which is easily detected on physical examination. In addition, an ultrasound can also easily confirm this finding.

Aortic sclerosis often does not significantly affect the function of the heart valve. In fact, one in four adults over the age of 65 has unrecognized aortic valve sclerosis. Until recently, this minor abnormality was felt to be harmless and raised little concern.

Significant calcification of the aortic valve leaflets can reduce the size of the valve’s opening, and eventually require the need for aortic valve surgery. There have been previous clinical studies that have demonstrated that aortic valve calcification is a progressive disorder, and that over time minor disease may eventually result in the need for valve replacement. Aortic valve sclerosis, which represents only minor calcium deposits in the heart, was felt to be a benign disorder or a normal part of the aging process. Recent research, however, has demonstrated that aortic sclerosis may increase the risk of a myocardial infarction or cardiovascular death. These findings were somewhat of a surprise.

An article published by Dr. Otto in the New England Journal of Medicine demonstrated approximately 50 percent increased risk of death from cardiovascular causes when aortic sclerosis was present. Surprisingly, this was in the absence of significant obstruction of the leaflets. This finding would indicate that a simple screening procedure, such as an echocardiogram, may help assess or predict the risk of heart disease in people without significant symptoms. No longer can we assume that this minor thickening of the aortic valve is a benign or normal finding of aging.

It is not necessarily recommended that routine echocardiograms are to be done on everyone, however, if your doctor detects a heart murmur using a stethoscope, further evaluation may be warranted. It is believed that this finding should be viewed as a marker for future cardiovascular events, such as possible myocardial infarction. This finding becomes even more important when detected in patients younger than 65 years of age, provided that the patient does not have congenital abnormalities of the heart valve.

There has been a recent study that also demonstrated that the presence of aortic valve sclerosis predicted the presence of coronary artery calcification. This finding was presented at the annual meeting of the American College of Chest Physicians. What they found was that the presence of aortic valve calcification increased the likelihood of having significant coronary artery calcification, which is a marker for coronary atherosclerosis.

This recent finding should not raise undue concern among the many patients who previously felt that they were well and told that their ultrasounds were unremarkable. However, we do believe this finding does signal an increased risk and should create a heightened awareness of the possibility of associated cardiovascular disease. There is no specific treatment for aortic valve sclerosis at this time, although there are studies ongoing to determine whether lipid-lowering or cholesterol-lowering medications may reduce the degree of calcification.

Taking all of this into consideration, our recommendations would be as follows:

1) Aortic valve sclerosis represents increased risk for cardiovascular disease, including coronary artery disease. This is especially true when it is detected in patients less than 65 years of age.
2) This finding should provide impetus for progressive risk factor management, including better control of hypertension, as well as aggressive treatment of elevated cholesterol.
3) Consideration should be given to an exercise treadmill test when aortic valve sclerosis is detected.
4) If the calcium deposits are significant, and the murmur is quite prominent, there may be an indication for what is known as endocarditis prophylaxis. This is simply the need for antibiotic medication prior to surgical or dental procedures.

In conclusion, I agree with the statement by Dr. Carabello of the Houston Veterans Affairs Medical Center when he said that aortic valve sclerosis should be viewed “as a harbinger of future events”.

Mark H. Eaton, MD, FACC is affiliated with the Sacramento Heart & Vascular Medical Associates located in the Sacramento Heart Center. For more information about the Sacramento Heart & Vascular Medical Associates, visit their website at www.sacheart.com or call (916) 830-2080 and request information be mailed to you. Please address your cardiology-related questions to “Ask the Cardiologist”, 500 University Avenue, Sacramento, CA 95825. Selected questions will be answered in future columns.