Mitral annulus calcification: potential indicator of vascular disease and higher thromboembolic risk

Introduction: In CHA2DS2-VASc thromboembolic risk score, vascular diseases (V) include either prior myocardial infarction, peripheral arterial disease or aortic plaque, summarizing the patient’s atherosclero-tic burden. Despite this, thromboembolic risk scores used in atrial fibrillation (AF) patients do not include mitral annular calcification (MAC) as a potential indi-cator of vascular disease.

Methods: T ish case-control study retrospectively assessed the relationship between MAC and thrombo-embolic risk scores (CHADS2 and CHA2DS2-VASc) in non-valvular AF patients (paroxysmal and non-paro-xysmal). We compared thromboembolic risk scores va-lue, clinical and transthoracic echocardiographic data in AF patients with and without MAC. The presence and severity of MAC was assessed in parasternal short axis and apical four chamber views. It was qualitati-vely defined as either mild, moderate or severe based on echodensity and extension in mitral annulus ring. MAC of >4 mm thickness was also considered severe.

Results: We included 103 patients: mean age 72.6 ± 9.9 years, 44.7% male, 83.5% hypertensive, 30.1% diabetic, 79.6% with heart failure, 40.8% were in atrial fibrillati-on and 7.8% had a history of stroke/transient ischemic stroke. We identified MAC in 50.5% patients: 15.7% severe, 50.3% moderate, 34% mild. Mean CHADS2 and CHA2DS2-VASc were 2.56 ± 1.213 and 4.57±1.61, respectively. In MAC patients, both scores tended to increase with a mean of 2.88 ± 1,114, p=0.003 and 5.211 ± 1.51, p<0.001 as compared with control (2.23 ± 06 and 3.92 ± 1.46), respectively. The presence of MAC was a risk factor for vascular disease (OR=2.47, χ2=34.32, p<0.001). Moreover, the AUC for CHA-2DS2-VASc, CHADS2, and MAC was 0.73 (95% CI, 0.63-0.82) and 0.65 (95% CI, 0.54-0.75), respectively. Both scores showed higher AUC in women: 0.79 (95% CI, 0.67-0.91) for CHA2DS2-VASc and 0.68 (95% CI, 0.54-0.82) for CHADS2. Left ventricular ejection frac-tion (LVEF) negatively correlated with the presence of MAC (r=-0.254, p=0.01). Sinus rhythm patients with MAC showed significantly decreased LVEF as compa-red to those without MAC (55.73 ± 12.3% vs. 46.96 ± 14.5%, p=0.013). The difference was not significant in AF patients (46.83 ± 10.6% vs. 45.92 ± 11.59, p=0.79).

Conclusions: The presence of MAC, irrespective of se-verity, correlates very well with both vascular disease and thromboembolic risk scores. Therefore, we con-sider that MAC might be a potential indicator of vas-cular disease and of higher thromboembolic risk. This study raises the question whether inclusion of MAC in thromboembolic risk scores as an indicator of vascular disease (V) might increase their predictive value.

ISSN – online: 2734 – 6382
ISSN-L 1220-658X
ISSN – print: 1220-658X
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CODE: 379
CME Credits: 10 (Romanian College of Physicians)