What is the prognosis of a 64-year-old male with degenerative aortic valve disease, concentric left ventricular (LV) hypertrophy, and left ventricular diastolic dysfunction with a preserved left ventricular ejection fraction (LVEF) of 70%?

From the Guidelines

The prognosis for a 64-year-old male with degenerative aortic valve disease, concentric left ventricular hypertrophy, and left ventricular diastolic dysfunction with preserved ejection fraction (70%) is generally favorable with appropriate management, though careful monitoring is essential. This patient should be followed by a cardiologist every 6-12 months with regular echocardiograms to track disease progression, as recommended by the 2021 ACC/AHA guideline for the management of patients with valvular heart disease 1. Medical therapy typically includes blood pressure control with ACE inhibitors like lisinopril (10-40 mg daily) or ARBs such as losartan (50-100 mg daily), along with diuretics like hydrochlorothiazide (12.5-25 mg daily) if fluid retention occurs. Beta-blockers such as metoprolol (25-200 mg daily) may help manage symptoms and control heart rate. The preserved ejection fraction (70%) is a positive prognostic factor, though diastolic dysfunction indicates impaired ventricular filling. Disease progression varies individually, but patients often remain stable for years before potentially requiring valve intervention. Warning signs requiring immediate medical attention include increasing shortness of breath, chest pain, syncope, or decreased exercise tolerance. If the aortic valve disease progresses to severe stenosis or regurgitation, surgical valve replacement or transcatheter aortic valve implantation (TAVI) may become necessary, especially if symptoms develop or left ventricular function begins to deteriorate, as suggested by the 2021 study on the advantages, pitfalls, and limitations of guideline-directed medical therapy in patients with valvular heart disease 1.

Some key points to consider in the management of this patient include:

• The importance of regular monitoring and follow-up with a cardiologist to track disease progression and adjust treatment as needed 1.
• The use of medical therapy, such as ACE inhibitors and beta-blockers, to manage symptoms and control heart rate 1.
• The potential need for valve intervention, such as surgical valve replacement or TAVI, if the disease progresses to severe stenosis or regurgitation 1.
• The importance of addressing comorbidities, such as hypertension, to slow disease progression and improve outcomes 1.

Overall, the goal of management is to slow disease progression, improve symptoms, and prevent complications, with the ultimate goal of improving morbidity, mortality, and quality of life for the patient.

From the Research

Prognosis of Degenerative Aortic Valve Disease

The prognosis of a 64-year-old male with degenerative aortic valve disease, concentric left ventricular (LV) hypertrophy, and left ventricular diastolic dysfunction with a preserved left ventricular ejection fraction (LVEF) of 70% can be understood through the following points:

• The patient's condition is characterized by diastolic heart failure, which has a significant effect on mortality (5-year mortality rate is 25% to 35%) and morbidity (1-year readmission rate is 50%) 2.
• The diagnosis of diastolic heart failure can be made when a patient has both symptoms and signs on physical exam of congestive heart failure (CHF), and normal left ventricular volume and ejection fraction 2.
• Left ventricular diastolic dysfunction (DD) and diastolic heart failure (HF) are due to alterations of myocardial diastolic properties, and arterial hypertension associated to LV concentric remodelling is the main determinant of DD 3.
• Despite an apparent lower death rate in comparison with LV systolic HF, long-term follow-up (more than 5 years) show similar mortality between the two kinds of HF 3.
• The therapy of LV DD and HF is not well established, but ACE-inhibitors, angiotensin inhibitors, aldosterone antagonists, and beta-blockers show potential beneficial effect on diastolic properties 2, 3.
• The use of renin-angiotensin-aldosterone system blockade has been shown to reduce all-cause mortality and cardiovascular events in patients with aortic regurgitation 4.
• ACE inhibitors/ARBs do not increase the risk of adverse outcomes in patients with aortic stenosis but may delay valve replacement, and beta-blockers do not appear to worsen outcomes in patients with chronic aortic regurgitation 5.

Treatment Options

Treatment options for the patient may include:

• Symptom-targeted therapy: decrease pulmonary venous pressure using diuretics and long-acting nitrates, maintain atrial contraction and atrial ventricular synchrony, reduce heart rate using beta-adrenergic blockers and calcium channel blockers 2.
• Disease-targeted therapy: prevent or treat myocardial ischemia, prevent or regress left ventricular hypertrophy 2.
• Mechanism-targeted therapy: modify neurohumoral activation using renin, angiotensin, and aldosterone system antagonists, endothelin antagonists, nitric oxide agonists, and atrial natruretic peptide agonists 2.
• The use of ACE inhibitors or ARBs, which has been shown to reduce all-cause mortality and cardiovascular events in patients with aortic regurgitation 4.