Approxiamately two out of 100 people above the age of 75 develop aortic stenosis (AS), and due to an ageing population, the prevalence of AS is increasing. The treatment involves insertion of a mechanical or biological heart valve during open-heart surgery (AVR) or the catheter-based method (TAVI).
Measurements of morbidity and mortality do not fully describe the patients’ physical, functional, emotional and mental well-being. Patient-reported outcomes research has the means to put the patient’s point of view on the agenda in AS care, and to fully grasp the temporal characteristics of living with AS. Patient-reported outcomes need to be evaluated at all stages of AS; from diagnosis and onset of symptoms, through various treatment modalities, and during short and long-term follow-up after surgery.
To date, most existing studies include few patients and short follow-up time. However, the greatest gap in the literature of heart valve disease includes the failure to evaluate self-reported health status in patients with AS who have not undergone AVR. Information on older patients with AS is of special importance because of the new treatment with transcatheter aortic valve implantation (TAVI) which is developed for patients with severe AS who are not suitable candidates for open heart surgery. In addition, a deeper understanding of the implications on patient’s daily life with a mechanical aortic valve; especially the closing sound of the valve, risk of infection and the life-long anticoagulation therapy, is needed.
The aortic valve is one of four heart valves, and controls the blood flow from the heart to the rest of the body. If this valve becomes too narrow, the condition is called aortic stenosis. Calcific aortic valve disease is the most common cause of AS among adults in the western world and the prevalence increases with age.Patients have a good prognosis as long as they remain asymptomatic, however, once the classic symptoms of angina, syncope, or dyspnoea develop, the prognosis drastically worsen if AVR is not performed. After the onset of symptoms, average survival is 2 to 3 years in patients who do not undergo AVR, with a high risk of sudden death. The most common treatment for AS is aortic valve replacement (AVR) with open heart surgery.
The purpose of the study
The purpose of this study was to examine factors that affect physical and mental health in people with AS; both those who have undergone valve surgery, and those who are not suited for surgical treatment. Those who had not undergone surgery when they received a questionnaire were followed for 18 months regarding further treatment and survival. In addition, the study purpose was to gain a deeper understanding, through interviews, of how patients adapted to living with a mechanical valve.
Completion of the study
All who had been treated for AS with open-heart surgery at Haukeland University Hospital from 2000 - 2012, were invited to participate in the study. Data from 1048 patients, through patient report and medical records were analysed. As many as 77% of those who received the questionnaire responded. Data on physical and mental health were compared to data from the general Norwegian population. In addition, 20 people were interviewed on how they adapted to living with a mechanical heart valve.
The study gave us important information about of the need of follow-up for patients with aortic stenosis, both before and after surgical treatment.
Financing: Western Norway Regional Health Authority, Bergen Hospital Trust and the Norwegian Nurses Association.
The project has generated 1 PhD, as well as 4 master’s degree thesis and several specialisation assignments in clinical cardiovascular nursing.
Results from the study
Factors that are connected to poorer health after valve surgery
In total, 912 patients (77%) responded to the questionnaire. Of these, 63% were men, and the mean age was 63 years. The time passed since surgery, was on average 7 years. The factors connected to poorer health were: low education level, a high degree of symptoms of AS, additional diseases to aortic stenosis, symptoms of anxiety and depression, as well as living alone. Both men and women reported poorer physical and mental health than those at similar age in the general population, especially in the higher age groups. Implementing new screening protocols for psychosocial risk factors and individualized rehabilitation program may contribute to improved health in AVR patients.
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Symptoms of aortic stenosis affect both physical and mental health
Of those responding to the questionnaire, 136 had not yet received surgical treatment.. They were, on average, 79 years old, 53% were men, and 77% had symptomatic aortic stenosis. Dyspnoea was the most frequent reported symptom. Those who had symptoms, reported lower physical and mental health compared to those without symptoms. In addition, symptomatic patients had a higher occurrence of anxiety and depression. After 18 months, 117 (86%) were still alive, 20% had been treated with open-heart surgery, and 7% with a catheter-based method (TAVI). Several patients who had symptoms of aortic stenosis and clinical findings of serious aortic stenosis, had not yet been treated with AVR or TAVI 18 months later, despite recommendations from international guidelines.
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Most people adapt well to living with a mechanical heart valve
Patients in the interview study were between 24 and 74 years old. They adapted to living with a mechanical heart valve in different ways. Having to take anticoagulation medicine (warfarin) for the rest of their lives was considered to be most troublesome. For some, the audible clicking sound from the valve was disruptive, especially when they were going to sleep, and in various social settings. They had sparse knowledge on how foods with vitamin K can affect the warfarin treatment.
Patient counselling and adequate follow-up can make patients with mechanical aortic heart valves more confident and competent to manage their own health. We recommend that patients should participate in a rehabilitation program following cardiac surgery. Several people requested the opportunity to measure INR and dose out the warfarin themselves. This is now an established education offered at Bergen Hospital Trust.
Cardiovascular nurses have little knowledge about treatment with warfarin
One of the findings of the previously mentioned interview study, was that the patients had little knowledge about interactions of warfarin and various medicines and foods with a high content of vitamin K. At a European congress in 2013, we therefore examined the knowledge of cardiovascular nurses on this topic. The results show that European cardiac nurses need to improve their knowledge and practice patterns on oral anticoagulation therapy. This area of knowledge is important in order to deliver optimal care to cardiac patients and to minimise adverse effects of the treatment.
Kjersti Oterhals; Intensive care nurse, Nurse researcher, Department of Heart Disease, Haukeland University Hospital, and Associate professor at the Western Norway University of Applied Sciences.
Tone M. Norekvål; Professor, University of Bergen and the Western Norway University of Applied Sciences. Leader of PROCARD Research group, Department of Heart Disease, Haukeland University Hospital.