Combined Cardiac Damage Staging by Echocardiography and Cardiac Catheterization in Patients With Clinically
Marta Belmonte1, Pasquale Paolisso2, Dario Tino Bertolone1
1Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium; Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy.
Insights
Combining cardiac damage staging from echocardiography and right heart catheterization improves mortality prediction in aortic stenosis patients. This integrated approach offers enhanced prognostic stratification, particularly for identifying high-risk individuals.
Area of Science:
- Cardiology
- Cardiovascular Imaging
- Clinical Risk Stratification
Background:
- Cardiac damage (CD) staging is crucial for risk stratification in aortic stenosis (AS).
- Transthoracic echocardiography (TTE) and right heart catheterization (RHC) are used for CD staging.
- The prognostic value and reclassification rate of RHC versus TTE in AS patients require further investigation.
Purpose of the Study:
- To assess the prognostic value and reclassification rate of RHC compared to TTE in CD staging for AS patients.
- To identify patients who would benefit from RHC for improved prognostic stratification.
- To test the prognostic value of combined CD staging using both TTE and RHC.
Main Methods:
- An observational cohort study of 432 AS patients undergoing both TTE and RHC.
- Patients were categorized into moderate/asymptomatic severe (m/asAS) and symptomatic severe (ssAS) AS groups.
- Survival analysis using Kaplan-Meier curves and prognostic accuracy assessment via ROC analysis and Delong test.
Main Results:
- Both TTE- and RHC-derived staging systems demonstrated prognostic value, with moderate agreement.
- TTE assigned more patients to stage 2 than RHC; 40-50% of TTE stage 2 patients were upstaged by RHC.
- Combined CD staging integrating TTE and RHC was more accurate in predicting mortality than TTE alone.
Conclusions:
- Combined CD staging using TTE and RHC is more accurate for predicting mortality in m/asAS and ssAS patients than TTE alone.
- Integrating RHC into CD staging significantly improves prognostic stratification in a subset of AS patients.
- This approach aids in identifying patients who may benefit from more intensive management strategies.
Background:
Cardiac damage (CD) staging enhances risk stratification in patients with clinically significant aortic stenosis (AS). We aimed to assess the prognostic value and reclassification rate of right heart catheterization (RHC) compared with transthoracic echocardiography (TTE) in characterising CD staging at 3-year follow-up in patients with clinically significant AS, to identify patients that would benefit from RHC for prognostic stratification, and to test the prognostic value of combined CD staging.
Methods:
An observational cohort study of 432 AS patients undergoing TTE and RHC were divided into moderate or asymptomatic severe (m/asAS) and symptomatic severe (ssAS) AS. Kaplan-Meier curves were used to compare survival. The accuracy in prognostic stratification was tested by area under the receiver operating characteristic curve analysis and Delong test.
Results:
In both cohorts, TTE- and RHC-derived staging systems had prognostic value, although the agreement between them appeared moderate. A higher proportion of patients were assigned to stage 2 by TTE than by RHC. Patients in TTE-derived stage 2 had a high reclassification rate, with 40%-50% presenting with right chamber involvement (stages 3-4) according to RHC. Discordant cases were significantly older, with higher prevalence of atrial fibrillation, markedly elevated N-terminal pro-B-type natriuretic peptide, and higher indexed left atrial volume, E/e', and systolic pulmonary artery pressure vs concordant cases (P < 0.05). The combined CD staging, integrating TTE and RHC, was more accurate in predicting mortality than the TTE-derived system (P < 0.05).
Conclusions:
In patients with m/asAS and ssAS, the combined CD staging, derived from TTE and RHC, was more accurate in predicting mortality than TTE alone. In a subset of AS patients, the integration of RHC may significantly improve prognostic stratification.
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