Interface between valve disease and ischaemic heart disease.

he association of coronary artery disease with heart valve disease is frequently encountered and it can be expected that this association will become more common because of the evolution in the epidemiology of valvar diseases. Degenerative lesions are now the most frequent cause of valve disease in western countries and they frequently occur in old patients, who are also at higher risk for atherosclerotic disease. The association of calcified aortic stenosis and coronary heart disease is the main problem, because it is the most frequently encountered association and because it raises specific questions , particularly in regard to the detection and management of both pathologies. Despite many reports in the literature, recently published guidelines point out the fact that concern remains regarding the optimal strategies for diagnosis and treatment of coronary artery disease in patients with valve disease. Calcific aortic stenosis associated with coronary artery disease Frequency of coronary artery disease in patients with calcified aortic stenosis The frequency of coronary artery disease in patients with calcified aortic stenosis can be correctly assessed only in studies comprising systematic coronary angiography, regardless of the symptoms. The frequency of associated coronary disease varies according to the characteristics of the population involved, in particular age and, to a lesser degree, the geographic origin. Series of patients with calcific aortic stenosis whose mean age is between 60 and 70 years reported 30–50% of associated significant coronary artery disease (at least one stenosis > 50% or 70% of vessel diameter). Coronary artery disease has been reported in more than 50% of patients aged > 70 years 2 and, of patients aged > 80 years, in 65% in series from the USA 3 and 41% in a British series. 4 Series published in the 1960s and '70s led certain authors to suggest that aortic stenosis could have a protective role against coronary atherosclerosis. This was in fact probably only the consequence of a selection bias in series in which the indication of coronary angiography depended on the symptoms. Patients with aor-tic stenosis and coronary disease became symptomatic earlier in the course of their disease, which could explain the lower incidence and severity of coronary disease than in patients without valve lesions. More recent studies including systematic coronary angio-graphy report frequent association of coronary disease, with a majority of multivessel disease, and therefore do not support this hypothesis of a protective eVect. Calcific aortic stenosis and coronary …