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Surveillance of cardiovascular risk in the normotensive patient with repaired aortic coarctation
Lorna Swan1, Mustafa Kraidly, Isabelle Vonder Muhll
1Adult Congenital Heart Programme, Department of Cardiology, Royal Brompton & Harefield NHS Trust, Imperial College, London, UK. lornaswan@yahoo.com
Insights
Repaired coarctation of the aorta patients show abnormal vascular characteristics despite good outcomes. Non-invasive methods can identify these risks for better cardiovascular surveillance.
Area of Science:
- Cardiovascular science
- Medical imaging
- Vascular biology
Background:
- Repaired coarctation of the aorta (CoA) is linked to premature atherosclerosis and cardiovascular events, even in normotensive individuals.
- Current risk stratification relies on brachial blood pressure, neglecting complex aortic waveform pulsatility.
- Improved risk assessment is needed for patients with repaired CoA.
Purpose of the Study:
- To assess aortic waveform pulsatility components in patients with repaired CoA.
- To identify potential non-invasive techniques for enhanced cardiovascular risk stratification.
Main Methods:
- Prospective study involving patients with repaired CoA and matched controls.
- Applanation tonometry for pulse wave morphology assessment.
- B-mode ultrasound and cardiac MRI for carotid intima-medial thickness and left ventricular mass.
Main Results:
- Coarctation patients exhibited elevated peripheral and central pulse pressures compared to controls.
- Earlier reflected pressure wave return and increased tension time index (TTI) were observed in coarctation subjects.
- Reduced sub-endocardial viability index (SVI) was noted in coarctation patients, despite normal brachial blood pressure and central augmentation index.
Conclusions:
- Patients with repaired CoA can have favorable mid-term outcomes with preserved vascular reactivity.
- Subtle vascular abnormalities persist, potentially increasing long-term cardiovascular risk.
- Non-invasive assessments can characterize sub-clinical abnormalities for improved long-term surveillance.
Background:
Repaired coarctation of the aorta is associated with premature atherosclerosis and an increased risk of cardiovascular events even in normotensive subjects. To date clinical risk stratification has focused on brachial blood pressures ignoring the complex pulsatility of the aortic wave form. The aim of this study was to assess components of this pulsatility in a clinical setting and to suggest possible techniques to improve risk stratification.
Methods:
This was a prospective study recruiting patients from a tertiary referral centre. Pulse wave morphology was assessed using applanation tonometry. B-mode ultrasound and cardiac magnetic resonance were used to assess carotid intimal-medial thickness and left ventricular mass.
Results:
Forty-six subjects with repaired coarctation of the aorta (range 16-62 years; mean 31 years) and 20 matched controls were studied. Baseline brachial systolic and diastolic blood pressures were not statistically different between the 2 groups. Peripheral (62.5 mmHg (11.3) vs. 50.6 mmHg (15.0), p=0.0008) and central (34.5 mmHg (7.7) vs. 28.7 mmHg (4.7), p=0.005) pulse pressures were elevated in the coarctation patients compared to controls. The reflected pressure wave returned to the ascending aorta earlier in the coarctation group (p=0.007) and the tension time index (TTI) was increased (p=0.03). The sub-endocardial viability index (SVI) was reduced in the coarctation subjects (159 (33) vs. 186 (31)%; p=0.009) but there was no differences in central augmentation index (p=0.35).
Conclusions:
This study demonstrates that there are patients with repaired coarctation who have an excellent mid-term outcome free from ventricular hypertrophy, carotid intima medial thickening and with relatively preserved vascular reactivity. However even in this "best outcome" cohort there were abnormal vascular characteristics that may predispose to increased cardiovascular risk. Simple non-invasive investigations can more extensively characterise these sub-clinical abnormalities and by utilised in long-term surveillance.
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