Abstract
Degenerative aortic stenosis (AS) and coronary artery disease (CAD) are the most prevalent cardiovascular diseases in developed countries, and they coexist in up to 50% of patients. The pathophysiological rationale behind concomitant AS and CAD is discussed in detail in this review, together with prognostic implications. Detecting CAD in patients with AS may be challenging, as AS may mask the existence and symptoms of CAD. The safety and reliability of invasive and non-invasive physiological assessment for epicardial coronary disease are also a matter of debate. Finally, the selection and timing of optimal treatment of CAD in patients with severe AS are still unclear. Given the aging of the population, the increase in the prevalence of AS, and the ongoing paradigm shift in its treatment, controversies in the diagnosis and treatment of CAD in the setting of AS are deemed to grow in importance. In this paper, we present contemporary issues in the diagnosis and management of CAD in patients with severe AS who are transcatheter aortic valve implantation (TAVI) candidates and provide perspective on the treatment approach.
Highlights
Degenerative aortic stenosis (AS) and coronary artery disease (CAD) are among the most prevalent cardiovascular diseases in industrialized countries, and their co-occurrence is common [1,2]
In line with what has been shown in other clinical settings [55], in a propensity matched study, the use of fractional flow reserve (FFR) in patients with moderate or severe AS and at least one intermediate coronary lesion significantly impacted clinical practice, resulting into deferral of aortic valve replacement, more patients treated with percutaneous coronary intervention (PCI), and in patients treated with coronary artery bypass grafting (CABG), into less venous grafts and anastomoses without increasing adverse events up to five years [56]
In another retrospective study conducted in patients undergoing transcatheter aortic valve implantation (TAVI), FFRguidance was associated with better major adverse cardiovascular and cerebrovascular event-free survival compared with the angio-guided group at two years (92.6% vs. 82%; p = 0.035) [57]
Summary
Degenerative aortic stenosis (AS) and coronary artery disease (CAD) are among the most prevalent cardiovascular diseases in industrialized countries, and their co-occurrence is common [1,2]. The concerns encompass the diagnosis of CAD, the assessment of the severity of epicardial artery stenosis, and the selection and timing of optimal treatment of CAD. The latter is important as, unlike patients undergoing surgical aortic valve replacement (SAVR), the most appropriate management of CAD in patients undergoing percutaneous transcatheter aortic valve implantation (TAVI) is yet to be codified. The impact of CAD and its treatment with percutaneous coronary intervention (PCI) on clinical outcome remains unclear in these patients [6,7,8]. We present contemporary issues in the diagnosis and management of CAD in patients with severe AS who are TAVI candidates, and provide perspective on the treatment approach
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