Decisions regarding coronary revascularization of patients with coexisting aortic stenosis (AS) and coronary artery disease (CAD) should be based on understanding this complex relationship, using appropriate coronary assessment and consensus within a multidisciplinary team, say the authors of a new review.
Published online Monday and in the Oct. 11 issue of JACC: Cardiovascular Interventions, the state-of-the-art review notes that AS and CAD frequently coexist, with up to two thirds of patients with AS having significant CAD.
“Given the challenges when both disease states are present, these patients require a tailored approach diagnostically and therapeutically,” said the authors, led by Kush P. Patel, MBBS, from University College London and St. Bartholomew’s Hospital, London.
“In this review we evaluate the complexities of coronary hemodynamic parameters in patients with AS and strategies to assess CAD in this patient population, and we examine the evidence for revascularization and its timing in the setting of AS,” the authors said.
“On the basis of the best available evidence, we propose an algorithm for the investigation and management of CAD in patients undergoing aortic valve replacement.”
Patel and colleagues noted that because CAD and AS share similar etiologies and pathophysiologic mechanisms, they frequently coexist.
“Both diseases can also cause similar symptoms, including angina and breathlessness, and both affect coronary hemodynamic status,” they noted, adding that this ultimately presents a dilemma regarding the relative contribution of coexisting CAD on symptoms and prognosis, the optimal method of assessing CAD severity, and the best management strategy for revascularization.
The team noted that current guidelines (Level of Evidence: C) recommend concomitant revascularization in patients undergoing surgical aortic valve replacement or transcatheter aortic valve replacement (TAVR), with an angiographically defined coronary stenosis of >50% or 70%.
“However, using this approach to guide revascularization has its limitations, and a physiologically guided strategy may improve outcomes,” they said.
The authors said that diagnostic and treatment alternatives remain ambiguous and highly debated in the area. For example, revascularization in patients undergoing aortic valve replacement can benefit certain patients in whom CAD is either prognostically or symptomatically important; however, identifying this cohort of patients “is challenging and as yet incomplete.”
“Among patients who present acutely, the predominant lesion (AS vs CAD) must be identified to guide further management,” they said. “This can be challenging, as both acute decompensated AS (ADAS) and acute coronary syndrome can present with an increase in cardiac troponin, electrocardiographic changes, and similar symptoms.”
As a result, they noted that clinical evaluation, coronary angiography and echocardiography are all required to differentiate ADAS and acute coronary syndrome.
“If acute coronary syndrome is the predominant condition, PCI [percutaneous coronary intervention] should be undertaken first. However, if ADAS is the predominant condition, valve replacement should be undertaken first, with studies supporting the feasibility of TAVR in ADAS,” they said.
However, Patel and colleagues noted that performing PCI after TAVR can be “technically challenging” because access to the coronary ostia can be partially obstructed – adding that fundamental to all management decisions is an evaluation by the multidisciplinary team, so that findings can be discussed, benefits and risks weighed, and a joint management decision established.
They said that for patients deemed appropriate for revascularization, a bleeding-risk assessment is helpful in decision making – adding that although risk stratification tools have not been developed for TAVR patients, scores such as HAS-BLED and PRECISION-DAPT can help gauge the bleeding risk.
“Where equipoise remains, performing valve replacement in the first instance, using a prosthesis that will permit future revascularization, is a reasonable option,” the authors recommended.
“On the basis of the best available evidence, we propose an algorithm for the investigation and management of CAD in patients undergoing aortic valve replacement,” they said. “This proposed algorithm for revascularization among patients undergoing valve replacement considers current practices, expert opinion, and existing evidence.”
Patel KP, Michail M, Treibel TA, et al. Coronary Revascularization in Patients Undergoing Aortic Valve Replacement for Severe Aortic Stenosis. JACC Cardiovasc Interv 2021;14: 2083–2096.
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