Valvular Heart Disease Increasingly Prevalent in Older Americans

Soundos K. Moualla, MD

Valvular heart disease is becoming more prevalent in the US’ aging population—enough so that one expert described the issue as a national health crisis.

New data presented at the American College of Cardiology (ACC) 2022 Scientific Sessions in Washington, DC, this weekend showed the contemporary prevalence of valvular hear diseases including aortic stenosis, mitral stenosis, mitral regurgitation, aortic regurgitation, tricuspid regurgitation are increased among patients aged ≥65 years old.

The findings additionally showed tricuspid regurgitation may be more prevalent among Americans than previously thought, and that female patients are generally more likely than male patients to suffer more severe disease.

In an interview with HCPLive during ACC 2022, investigator Soundos K. Moualla, MD, cardiology at Yavapai Regional Medical Center, discussed the impact of the new findings, the rationale behind less-detected tricuspid regurgitation, and the burdens of disparate valvular heart disease among older patients and women.

HCPLive: What exactly is the burden of valvular heart disease on our national population?

Moualla: I believe it is a serious epidemic that we're dealing with, valve disease in this country. It is causing a lot of burden on the medical healthcare system, and the burden is by volume and under-treatment that leads to repetitive hospitalization, recurrent admissions with congestive heart failure, and patients becoming revolving doors in and out of the hospital. This study really highlights some amazing findings and has certain features that are unique, that gives us a very true perspective. Number one, it is an extremely large study. It is over 700,000 patients—the largest in contemporary and prior literature available. It spans a variety of medical centers. So we try to eliminate the bias that one might have—let's say from referral to tertiary referral centers—so it involves smaller hospital, bigger, medium-sized hospitals all throughout the United States.

The surprising things that came out of the data is that tricuspid valve, which is often what's called the "forgotten valve," showed the highest prevalence of disease out of all the diseases that we look at. We often are deeply concerned with aortic stenosis, because of the deadly nature of the disease, and we also are very interested with mitral regurgitation for a variety of reasons. The surprise to us was that tricuspid valve carried the highest prevalence of over 7.09% as compared to the other valves. The second valve was the mitral regurgitation. That did not surprise us to be more than aortic stenosis; we knew that the burden would be more, just because there's so much pathology variation with mitral regurgitation. It was followed by the aortic stenosis, and then aortic insufficiency, and what have you.

Can you talk a little bit more about the clinical history of valve disease that leads the tricuspid to be referred to as the "forgotten valve?"

I think a lot of that came from the fact that we didn't really have a lot of therapeutic options for the tricuspid valve. And when the patients presented with severe tricuspid regurgitation, let's say as an isolated disease, the surgical options were there. But often these patients had profound RV dysfunction and their hemodynamic status is extremely poor, and the surgical outcomes were not ideal. Consequently, because we didn't know what to do for it and we didn't have a lot of options for what to do for it, we sort of forget about it.

What would be very interesting to ultimately dive into further analysis, once the statistical analysis is completed, is to look at the average body mass index for these patients. Is it that we are facing a obesity epidemic, and we are getting more pulmonary hypertension, for example? More sleep apnea, and that is leading to worsening of the right-side hemodynamics of the heart and consequently leading to the tricuspid? There is also further analysis to look at people who might have had pacemakers, for example, do we need to take a look? Is this an isolated anatomical tricuspid regurgitation with no pacemakers versus pacemakers or defibrillators? I think we have to keep in mind this study is looking at the prevalence of it.

I truly believe as we dive through it more to look at subclinical analyses of these patients—looking at their weight, BMI, presence of sleep apnea, the presence of devices—that will explain this higher prevalence of that. And I believe now, where we have so many other trials available and technologies available...and better therapeutic options that were not available to us previously, it's making us focus a lot more. The interesting thing in this pathology from the patients that we've dealt with who have, say, mitral and tricuspid, we see that even mild reduction in the degree of regurgitation of the valve leads to significant clinical improvement in these patients. So there is a lot we are learning on it. I think the beauty of the study is its highlight of the prevalence of this disease. And it warrants further statistical analysis to really understand what we treat, who we treat, and how do we treat.

Speaking to the "who" element of the analysis, it was particularly interesting to observe the age- and sex-related differences in valve disease prevalence. How do those findings impact current strategies and prioritizations of risk-stratification and initiation of care?

So, those are 2 separate issues, really, and to answer them, we need to look at them in an individual topic. The prevalence, it is not surprising that the older the patients gets, the more disease we're going to have. For variety of reason, we get more atherosclerotic disease process affecting the aortic valve. With regard to the mitral regurgitation, all aspects of the primary or secondary conditions do increase with age. And we are increasing in the median age population for men and women in this country, so we are facing a massive epidemic. On average, if you take all of them, you're dealing with more than 5% of the population in this country that's going to have a valve disease of some sort. And despite all the awareness and education, from a clinical point of view, here's still shortage of treatment of all aspects of aortic valve—even the ones that are classical. There is significant amount of under-recognition of severe aortic stenosis that's defined as moderate by some criteria. A lot of providers and practitioners still don't refer these patients until their symptoms are so severe.

I think this study would be a very powerful educational tool for all providers, cardiologists and non-cardiologists. I do believe that primary care physicians are a very important piece toward answering some of these questions about how to tackle this. I don't believe we should only just increase that awareness from a subspecialty point of view. Sometimes the primary care physician is the rate-limiting step of referring this patient or not. And if their symptoms are mild, or they have adapted their lifestyle and they don't move at all, they won't have any symptoms at all. Consequently, the providers will believe they're asymptomatic, where in reality they have significant valve disease that impacted their lifestyle significantly. So, age is important, I believe. We are trying to create some sort of collaboration with the American College of Physicians to increase the awareness of valve disease.

So, the gender aspect to me, as an interventional cardiologist, doesn't surprise me the in the least. Women in general have a different symptom profile than men when it comes to coronary disease. I often find that the the same is for valve disease. They have fatigue, shortness of breath, they might have vague symptoms—they just adapt to it. Historically, women don't complain as much as men. And thirdly, the medical community in general under-diagnoses and undertreats women compared to men. If we are looking at prevalence being higher in women than men, that's even more so highlights the importance of increased clinician awareness and education, and also patient-directed education.

The study, "Contemporary Prevalence of Valvular Heart Disease & Diagnostic Variability Across Centers," was presented at ACC 2022.