Should Patients with Heyde’s Syndrome Undergo Early Valve Intervention?

Keywords Aortic Valve Stenosis; Gastrointestinal Hemorrhage/complications; Percutaneous Coronary Intervention; Comorbidities; Mortality

The epidemiological profile of patients with aortic stenosis has changed with the aging of the population, characterized by an increase in associated comorbidities.¹ Thanks to the revolution in percutaneous aortic valve treatment, many patients who previously would have limited survival and quality of life have benefited from the possibility of curative treatment. On the other hand, the clinical challenges that arise in this population reinforce not only the consolidated relevance of the heart team but also of other specialties such as oncology and hematology.

The interesting study published in the current issue reinforces the importance of the association between Heyde’s syndrome and aortic stenosis, with increased bleeding in this population. However, it is important to highlight in this context the frequently associated comorbidities that may contribute to eventual digestive bleeding, such as the association between aortic stenosis and neoplasm, since both share the same risk factors, particularly colon cancer neoplasm.² This one presents with cardinal clinical signs: anemia and low gastrointestinal bleeding. In this context, the exclusion of neoplasm is mandatory, even in the suspicion of Heyde’s Syndrome. We can also describe other frequently associated comorbidities³ that add bleeding risk due to the therapy used, such as coronary artery disease, which usually uses antiplatelet therapy, or dual anti-aggregation after percutaneous coronary intervention with a drug-eluting stent.

Another example is the increased prevalence of atrial fibrillation.⁴ In this scenario, when Heyde’s Syndrome is present, there is an intrinsic maximization of bleeding once anticoagulation is used. Another clinical condition that is growing in the elderly population is cardiac amyloidosis, mainly by transthyretin. Another clinical condition growing in the elderly population is cardiac amyloidosis, mainly caused by transthyretin. The association with severe aortic stenosis is more common than previously thought, ranging between 12 and 16%.^5,6 Like aortic stenosis, its prevalence is higher in the elderly population; amyloid fiber acts directly in the coagulation cascade, favoring the emergence of spontaneous hemorrhagic events.⁷ Finally, not related to increased bleeding, but the impact that this may cause, the frailty of the patient with aortic stenosis.⁸ A patient with severe aortic stenosis, considered frail, has a less organic reserve to withstand any severe bleeding. It is known that the need for blood transfusion negatively impacts the morbidity and mortality of this population.⁹

The work of Rosa et al.¹⁰ reinforces the importance of a neglected association with a high rate of severe bleeding and the need for transfusion on admission, with an increased risk of mortality. The current recommendation for screening colonoscopy for colorectal cancer has been reduced to 45 years according to the U.S. Preventive Services Task Force. In addition, access to endoscopic procedures is not massively available to a large part of the population in our country, which increases risk since the diagnoses of angiodysplasia and neoplasia of the digestive tract are not routinely made. The article’s questioning is valid for several aspects: it reinforces the importance of actively researching angiodysplasia in this population. Therefore, it justifies a new look at the usual indications for intervention in aortic stenosis. Another point of weighting is the judicious use of platelet anti-aggregation in this population. Another interesting aspect raised in this study is the indication of valve intervention in these patients, regardless of the presence of symptoms or complicating factors, but this is still controversial. Finally, given the unique clinical fragility of a patient with severe aortic stenosis, it is always important to refer them to reference centers with access to multispecialty and more assertive decision-making.

• Short Editorial related to the article: Heyde’s Syndrome: Therapeutic Strategies and Long-Term Follow-Up

References

• ¹ Stefanini GG, Stortecky S, Meier B, Windecker S, Wenaweser P. Severe aortic stenosis and coronary artery disease. EuroIntervention. 2013 Sep 10;9 Suppl:S63-8.
• ² Frattini S, Troise G, Fucci C, Pressman GS, Faggiano P. Aortic valve stenosis and cancer: a common and complex association. Expert Rev Cardiovasc Ther. 2021 Apr;19(4):289-299.
• ³ Pepe M, Larosa C, Rosa I, Biondi-Zoccai G, Nestola PL, Di Cillo O, et al. Degenerative Severe Aortic Stenosis and Concomitant Coronary Artery Disease: What Is Changing in the Era of the “Transcatheter Revolution”? Curr Atheroscler Rep. 2020 May 26;22(5):17.
• ⁴ Alsidawi S, Khan S, Pislaru SV, Thaden JJ, El-Am EA, Scott CG, et al. High Prevalence of Severe Aortic Stenosis in Low-Flow State Associated With Atrial Fibrillation. Circ Cardiovasc Imaging. 2021 Jul;14(7):e012453.
• ⁵ Nitsche C, Scully PR, Patel KP, Kammerlander AA, Koschutnik M, Dona C, et al. Prevalence and Outcomes of Concomitant Aortic Stenosis and Cardiac Amyloidosis. J Am Coll Cardiol. 2021 Jan 19;77(2):128-39.
• ⁶ Castaño A, Narotsky DL, Hamid N, Khalique OK, Morgenstern R, DeLuca A, Rubin J, et al. Unveiling transthyretin cardiac amyloidosis and its predictors among elderly patients with severe aortic stenosis undergoing transcatheter aortic valve replacement. Eur Heart J. 2017 Oct 7;38(38):2879-87.
• ⁷ Schrutka L, Avanzini N, Seirer B, Rettl R, Dachs T, Duca F, et al. Bleeding events in patients with cardiac amyloidosis, Eur Heart J.2020;41(Suppl 2):ehaa946.2122. https://doi.org/10.1093/ejhjci/ehaa946.2122
  » https://doi.org/10.1093/ejhjci/ehaa946.2122
• ⁸ Afilalo J, Lauck S, Kim DH, Lefèvre T, Piazza N, Lachapelle K, et al. Frailty in Older Adults Undergoing Aortic Valve Replacement: The FRAILTY-AVR Study. J Am Coll Cardiol. 2017 Aug 8;70(6):689-700.
• ⁹ Apostolidou E, Aronow HD, Beale CE, Kolte D, Kennedy KF, Sellke FW, et al. Association Between Red Blood Cell Transfusion and Clinical Outcomes Among Patients Undergoing Transcatheter Aortic Valve Replacement. Ann Thorac Surg. 2019 Jun;107(6):1791-8.
• ¹⁰ Rosa VEE, Ribeiro HB, Fernandes JRC, Santis A, Spina GS, Paixão MR, et al. Heyde’s Syndrome: Therapeutic Strategies and Long-Term Follow-Up. Arq Bras Cardiol. 2021; 117(3):512-517.

Publication Dates

• Publication in this collection
  20 Sept 2021
• Date of issue
  Sept 2021