Prognostic Value Of Hs-Crp After Transcatheter Aortic Valve Implantation

HomeCirculation: Cardiovascular InterventionsVol. 11, No. 12Prognostic Value of hs-CRP After Transcatheter Aortic Valve Implantation Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBPrognostic Value of hs-CRP After Transcatheter Aortic Valve Implantation Diego Iglesias-Álvarez, MD, Diego López-Otero, MD, PhD, Rocío González-Ferreiro, MD, Xoan Sanmartín-Pena, MD, Belén Cid-Álvarez, MD, Ramiro Trillo-Nouche, MD and José Ramón González-Juanatey, MD, PhD Diego Iglesias-ÁlvarezDiego Iglesias-Álvarez Department of Cardiology, Complexo Hospitalario Universitario de Santiago, Spain (D.I.-A., D,L.-O., X.S.-P., B.C.-A., R.T.-N., J.R.G.-J.). CIBERCV (Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares), Santiago de Compostela, Spain (D.I.-A., D,L.-O., X.S.-P., B.C.-A., R.T.-N., J.R.G.-J.). Search for more papers by this author , Diego López-OteroDiego López-Otero Department of Cardiology, Complexo Hospitalario Universitario de Santiago, Spain (D.I.-A., D,L.-O., X.S.-P., B.C.-A., R.T.-N., J.R.G.-J.). CIBERCV (Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares), Santiago de Compostela, Spain (D.I.-A., D,L.-O., X.S.-P., B.C.-A., R.T.-N., J.R.G.-J.). Search for more papers by this author , Rocío González-FerreiroRocío González-Ferreiro Department of Cardiology, Complejo Asistencial Universitario de Salamanca, Spain (R.G.-F.). Search for more papers by this author , Xoan Sanmartín-PenaXoan Sanmartín-Pena Department of Cardiology, Complexo Hospitalario Universitario de Santiago, Spain (D.I.-A., D,L.-O., X.S.-P., B.C.-A., R.T.-N., J.R.G.-J.). CIBERCV (Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares), Santiago de Compostela, Spain (D.I.-A., D,L.-O., X.S.-P., B.C.-A., R.T.-N., J.R.G.-J.). Search for more papers by this author , Belén Cid-ÁlvarezBelén Cid-Álvarez Department of Cardiology, Complexo Hospitalario Universitario de Santiago, Spain (D.I.-A., D,L.-O., X.S.-P., B.C.-A., R.T.-N., J.R.G.-J.). CIBERCV (Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares), Santiago de Compostela, Spain (D.I.-A., D,L.-O., X.S.-P., B.C.-A., R.T.-N., J.R.G.-J.). Search for more papers by this author , Ramiro Trillo-NoucheRamiro Trillo-Nouche Department of Cardiology, Complexo Hospitalario Universitario de Santiago, Spain (D.I.-A., D,L.-O., X.S.-P., B.C.-A., R.T.-N., J.R.G.-J.). CIBERCV (Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares), Santiago de Compostela, Spain (D.I.-A., D,L.-O., X.S.-P., B.C.-A., R.T.-N., J.R.G.-J.). Search for more papers by this author and José Ramón González-JuanateyJosé Ramón González-Juanatey Department of Cardiology, Complexo Hospitalario Universitario de Santiago, Spain (D.I.-A., D,L.-O., X.S.-P., B.C.-A., R.T.-N., J.R.G.-J.). CIBERCV (Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares), Santiago de Compostela, Spain (D.I.-A., D,L.-O., X.S.-P., B.C.-A., R.T.-N., J.R.G.-J.). Search for more papers by this author Originally published14 Dec 2018https://doi.org/10.1161/CIRCINTERVENTIONS.118.007213Circulation: Cardiovascular Interventions. 2018;11:e007213There is a growing interest in the inflammation hypothesis because it is believed a new pathway to identify groups of patients who might benefit from targeted therapeutics.1 CRP (C-reactive protein) is a nonspecific acute phase reactant, classically related to inflammation and infection. Its blood concentration can rise significantly in cardiovascular disorders, such as atherosclerotic disease and prothrombotic conditions.2Degenerative aortic stenosis is the most common valvular heart disease in developed countries, and its prevalence is dramatically increasing. Moreover, in the past years, aortic stenosis has been identified as an inflammatory-based disease,3 sharing common pathophysiology with atherosclerosis, such as calcification, deposition of lipoproteins, and chronic inflammation.Persistently high levels of hs-CRP (high-sensitivity CRP) have been associated with rapid disease progression and increased cardiovascular mortality in patients affected by aortic stenosis.4 After transcatheter aortic valve implantation (TAVI), little is known about changes in hs-CRP and clinical outcomes.We aimed to investigate the correlation of baseline and 3-month follow-up levels of hs-CRP with all-cause mortality after TAVI. We conducted a retrospective observational study, including 399 consecutive patients that underwent TAVI at our institution from November 2008 to June 2017. Measurement of hs-CRP was part of clinical care. Information was retrieved from a computerized database. We recorded hs-CRP levels the day of intervention and after 3 months. The association between baseline characteristics and follow-up mortality was studied in a robust Cox proportional hazards model. Multivariate risk adjustment model was performed with all variables associated (P<0.05) with postdischarge mortality in the univariate Cox analyses. The ethics committee of the hospital approved the study protocol and the revision of the clinical history.At baseline, mean hs-CRP was 0.9±1.9 mg/dL (median, 0.4; interquartile range, 0.2–0.9 mg/dL; normal, 0.0–0.5 mg/dL]. After a median follow-up of 2.8±2.2 years (interquartile range, 1.1–4.3), overall mortality was 37.3% (144 patients). Adjustment for significant factors in multivariate analysis was performed: age, prior heart failure, anemia, nonfemoral vascular access, aortic regurgitation >II, in-hospital acute kidney injury, and Society of Thoracic Surgeons score. Baseline hs-CRP value was independently associated with all-cause mortality (hazard ratio, 1.14 per mg/dL; 95% CI, 1.01–1.29; P=0.036; Figure [A]). When subsequent hs-CRP values were evaluated (3 months after valve implantation), there was a mean increase of 0.06±1.49 mg/dL (median, 0.01; interquartile range, −0.19 to 0.29). hs-CRP changes were associated with mortality in a J-shape behavior (Figure [B]). After adjusting for baseline hs-CRP values, we observed that a rise in hs-CRP was associated with higher risk of mortality (hazard ratio, 1.18; 95% CI, 1.05–1.32; P=0.006). Conversely, when hs-CRP decreased, we did not find any association with mortality (hazard ratio, 1.19; 95% CI, 0.50–2.85; P=0.691). After examining hs-CRP values (baseline and after 3 months) and changes in valve hemodynamics, we found no significant association with peak or mean gradient, aortic valve area, or aortic regurgitation grade >II. Therefore, in our cohort, baseline hs-CRP was a prognostic marker of mortality, independent of hemodynamic changes after TAVI.Download figureDownload PowerPointFigure. Relationship between hs-CRP (high sensitivity C-reactive protein) values and mortality.A, Baseline hs-CRP and adjusted mortality predicted rate. B, Change in hs-CRP levels (between baseline and 3 mo post-TAVI) and observed death rate.The inflammatory hypothesis of atherothrombosis has been one of the latest spotlights in Cardiology. Kinetics of hs-CRP in TAVI have been previously described, with higher baseline and peak measurements after the procedure linked to adverse outcomes.5 Particularly, raised values of hs-CRP during the index admission have been related with infection as the contributing factor for 30-day mortality. Our study is the first analyzing trends in hs-CRP values and survival in the outpatient setting. Those with higher baseline levels of hs-CRP could be prone to higher mortality because of more advanced disease; a sustained inflammatory state over the years that in itself can explain the adverse outcomes of this population.Monitoring hs-CRP levels could be useful to spot individuals who may benefit of interventions (medical or nonmedical) to optimize their condition before undergoing the procedure or even considering it.Finally, there is 1 important limitation to our study that needs clarification. Levels of hs-CRP at 3 months were available in 70.7% of the baseline cohort (263 patients). Consequently, those who passed away (42 patients) or did not attend to follow-up clinic (15 patients) for obtaining blood tests were excluded from this part of the study. As mortality in the first 3 months after implantation is usually related to procedural complications, this analysis may apply only to those patients who underwent an uneventful valve replacement.In conclusion, we found that hs-CRP at baseline is an independent predictor of post-TAVI mortality. After 3 months of follow-up, the values tended to increase; its variation was related to mortality in a J-shape manner. Higher risk of mortality was observed in those who experienced an increase from baseline hs-CRP after the procedure. Closer surveillance and individually tailored medical therapy are needed for a better understanding of this, particularly high-risk subgroups.DisclosuresNone.Footnoteshttps://www.ahajournals.org/journal/circinterventionsDiego López-Otero, MD, PhD, Department of Cardiology, Hospital Clínico Universitario Santiago de Compostela, Travesía de la Choupana s/n, 15706 Spain. Email [email protected]esReferences1. Ridker PM, Everett BM, Thuren T, MacFadyen JG, Chang WH, Ballantyne C, Fonseca F, Nicolau J, Koenig W, Anker SD, Kastelein JJP, Cornel JH, Pais P, Pella D, Genest J, Cifkova R, Lorenzatti A, Forster T, Kobalava Z, Vida-Simiti L, Flather M, Shimokawa H, Ogawa H, Dellborg M, Rossi PRF, Troquay RPT, Libby P, Glynn RJ; CANTOS Trial Group. Antiinflammatory therapy with canakinumab for atherosclerotic disease.N Engl J Med. 2017; 377:1119–1131. doi: 10.1056/NEJMoa1707914CrossrefMedlineGoogle Scholar2. Yeh ET, Willerson JT. Coming of age of C-reactive protein: using inflammation markers in cardiology.Circulation. 2003; 107:370–371.LinkGoogle Scholar3. Galante A, Pietroiusti A, Vellini M, Piccolo P, Possati G, De Bonis M, Grillo RL, Fontana C, Favalli C. C-reactive protein is increased in patients with degenerative aortic valvular stenosis.J Am Coll Cardiol. 2001; 38:1078–1082.CrossrefMedlineGoogle Scholar4. Imai K, Okura H, Kume T, Yamada R, Miyamoto Y, Kawamoto T, Watanabe N, Neishi Y, Toyota E, Yoshida K. C-Reactive protein predicts severity, progression, and prognosis of asymptomatic aortic valve stenosis.Am Heart J. 2008; 156:713–718. doi: 10.1016/j.ahj.2008.04.011CrossrefMedlineGoogle Scholar5. Krumsdorf U, Chorianopoulos E, Pleger ST, Kallenbach K, Karck M, Katus HA, Bekeredjian R. C-reactive protein kinetics and its prognostic value after transfemoral aortic valve implantation.J Invasive Cardiol. 2012; 24:282–286.MedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Seoudy H, Shamekhi J, Voigtländer L, Ludwig S, Frank J, Kujat T, Bramlage P, Al-Kassou B, Sugiura A, Rangrez A, Schofer N, Puehler T, Lutter G, Seiffert M, Nickenig G, Conradi L, Frey N, Westermann D, Sinning J and Frank D (2022) C-Reactive Protein to Albumin Ratio in Patients Undergoing Transcatheter Aortic Valve Replacement, Mayo Clinic Proceedings, 10.1016/j.mayocp.2021.11.022, 97:5, (931-940), Online publication date: 1-May-2022. Chen W, Xiao Q, Fang Z, Lv X, Yao M, Deng M and Huang T (2021) Correlation Analysis between the Viral Load and the Progression of COVID-19, Computational and Mathematical Methods in Medicine, 10.1155/2021/9926249, 2021, (1-7), Online publication date: 8-Jun-2021. Takagi H, Kuno T, Hari Y, Nakashima K, Yokoyama Y, Ueyama H and Ando T (2020) Prognostic impact of baseline C‐reactive protein levels on mortality after transcatheter aortic valve implantation, Journal of Cardiac Surgery, 10.1111/jocs.14499, 35:5, (974-980), Online publication date: 1-May-2020. Tosu A, Kalyoncuoglu M, Biter H, Cakal S, Selcuk M, Çinar T, Belen E and Can M (2021) Prognostic Value of Systemic Immune-Inflammation Index for Major Adverse Cardiac Events and Mortality in Severe Aortic Stenosis Patients after TAVI, Medicina, 10.3390/medicina57060588, 57:6, (588) December 2018Vol 11, Issue 12 Advertisement Article InformationMetrics © 2018 American Heart Association, Inc.https://doi.org/10.1161/CIRCINTERVENTIONS.118.007213PMID: 30562090 Originally publishedDecember 14, 2018 Keywordsprognosisaortic valveinflammationtranscatheter aortic valve implantationC-reactive proteinPDF download Advertisement SubjectsAortic Valve Replacement/Transcatheter Aortic Valve ImplantationBiomarkersInflammation