Frequency, course and prognostic yield of valvular heart disease in the general population- Results from the STAAB cohort study
Authors: Chen M , Schmidbauer L , Cejka V , Sahiti F , Frantz S , Gelbrich G , Heuschmann P U , Stoerk S , Morbach C 
Published: January 2025

Abstract

Background
Valvular heart disease (VHD) is a major burden to public health. The complexity and the long asymptomatic phase of VHD pose significant challenges to its recognition and monitoring. Assuming gradual disease progression, the ACC/AHA define consecutive stages of VHD from "at risk" through "progressive stage" to "severe symptomatic VHD".

Purpose
To determine the frequency and course of VHD stages in the general population and to estimate their respective prognostic value regarding all-cause mortality.

Methods
The STAAB study recruited a representative sample of inhabitants of a medium-sized town in Germany stratified for sex (1:1) and age decades (30-79 years), who had no preceding diagnosis of heart failure. All participants underwent standardized transthoracic echocardiography (TTE). VHD was graded into stages A to D: stage A = at risk for valve dysfunction: valve deformity, sclerosis, mild mitral or tricuspid regurgitation (MR/TR); stage B = progressive valve dysfunction: mild or moderate aortic regurgitation or stenosis, mild mitral stenosis, moderate MR and TR; stage C/D VHD = asymptomatic/symptomatic severe valve dysfunction: severe valvular regurgitation or stenosis. The relevance of baseline markers with respect to VHD progression and all-cause mortality was analysed using multivariable model and Cox proportional hazards regression model, respectively.

Results
N=4943 STAAB participants (mean age 55±12 years, 52% women) with valid TTE entered our baseline analysis, and 24% of them were free from VHD. Stage A VHD was present in n=2694 (54%) participants, stage B in n=1056 (21%), and stage C/D in n=16 (0.3%). Participants with stage C/D VHD were older, more frequently male, and showed higher levels of N-terminal pro-B-type natriuretic peptide (NT-proBNP) and high-sensitivity troponin (Table). Over a median follow-up of 34 months (quartiles 30–41), 35 participants died. Stage C/D VHD (HR, 6.23 [95% CI, 1.24 – 31.34], p=0.026) was associated with all-cause mortality after adjusting for age and sex. N=3833 participants (mean age 58 ±11 years, 52% women) underwent a repeat echocardiography at follow-up. In this sample, 10% of stage A and 1.3% of stage B had progressed from baseline to higher VHD stages, respectively (Figure). Determinants of disease progression were E/e´ (stage A, OR 1.14 [95% CI, 1.03 –1.26], p=0.01) and NT-proBNP (stage B, OR 7.48 [95% CI, 1.38 –40.4], p=0.019) at baseline, respectively.

Conclusions
In this well-characterized population-based sample, we found a high prevalence of VHD stages A and B. Stage C/D VHD was associated with higher levels of cardiac injury indicators such as troponin and NT-proBNP as well as with a higher risk of death. The majority of individuals with stage A and B VHD was asymptomatic, but a sizable fraction showed VHD progression in the subsequent three years. Elevated E/e´ and NT-proBNP might be helpful in identifying patients at higher risk for disease progression.
Baseline characteristics
Distribution of VHD stages