Is there a relationship between aortic stenosis and coronary artery disease (CAD)?

Relationship Between Aortic Stenosis and Coronary Artery Disease

Yes, aortic stenosis (AS) and coronary artery disease (CAD) frequently coexist, with approximately two-thirds of patients with AS having significant CAD. 1

Epidemiology and Shared Pathophysiology

• CAD is present in up to 65% of patients undergoing transcatheter aortic valve replacement (TAVR), making it one of the most common comorbidities in the AS population 1
• Both conditions share common pathophysiological mechanisms and risk factors, including atherosclerotic processes that contribute to their frequent coexistence 2, 3
• The prevalence of CAD increases among elderly patients with severe AS since disease progression is strongly associated with age for both conditions 3
• Patients with concomitant AS and CAD are characterized by higher baseline risk profiles with a larger number of comorbidities compared to patients with isolated AS 3

Clinical Significance and Diagnostic Challenges

• Determining the relative contribution of AS versus CAD to symptoms is challenging because both conditions produce overlapping complaints, particularly angina and dyspnea 4, 5
• Severe AS interferes with hemodynamic assessment of intermediate coronary lesions, as the valve pathology itself can lead to subendocardial ischemia and angina pectoris independent of epicardial CAD 5
• Currently used coronary physiological indices (FFR, resting indices) are not validated in the AS population, and valve replacement has variable effects on these measurements 5
• Remodeling in AS increases susceptibility to myocardial ischemia, which can be compounded by concomitant CAD 4

Impact on Management and Outcomes

• Evaluation and modification of cardiac risk factors is important in patients with aortic valve disease to prevent concurrent CAD, though medical therapy cannot prevent or delay the AS disease process itself 1
• The number of patients undergoing concomitant coronary artery bypass grafting (CABG) and surgical aortic valve replacement (SAVR) doubled over the last decade, reflecting the high prevalence of this dual pathology 3
• In patients undergoing SAVR, the addition of CABG has been associated with improved long-term mortality, especially if CAD is complex, although it carries higher periprocedural risk 2
• Some studies have suggested higher 1-year mortality after TAVR in patients with CAD than in those without CAD 1

Treatment Considerations

• SAVR with CABG is appropriate for all patients with CAD and aortic stenosis when technically feasible, and represents the standard of care for combined severe stenoses involving proximal arteries 1
• SAVR without coronary revascularization is rarely appropriate if there is significant CAD involving the LAD, 3 vessels, or left main coronary artery 1
• The therapeutic impact of percutaneous coronary intervention (PCI) in patients undergoing TAVR is less well-established compared to surgical revascularization 2
• Decisions regarding coronary revascularization should be based on understanding the complex relationship between AS and CAD, using appropriate coronary assessment and consensus within a multidisciplinary heart team 4

Key Clinical Pitfalls

• Do not assume chest pain in AS patients is solely valvular in origin - systematic evaluation for CAD is essential as both conditions contribute to ischemic symptoms 4, 5
• Avoid relying solely on standard FFR measurements in AS patients as severe AS significantly affects coronary hemodynamics and interferes with accurate assessment of coronary lesion significance 5
• Recognize that AVR can improve coronary hemodynamic status and reduce ischemia, which may alter the significance of borderline coronary lesions post-procedure 4