[Elevated HDL is the main negative risk factor for coronary artery disease in the elderly patient with calcific aortic valve disease]

Abstract

In spite of high prevalences of hypertension and hypercholesterolemia, the majority of elderly patients admitted for aortic valve surgery due to calcific aortic valve disease (CAVD) do not have significant coronary artery disease (CAD).

Objective: To evaluate the lipid profile (LP) of patients undergoing surgery for CAVD and to correlate this with coronary angiographic data and prior cardiovascular risk factor profile.

Methods: This was a prospective observational cohort study of 264 consecutive patients aged >59 years (mean 72), 126 men (48%) and 138 women (52%). According to the angiographic presence (irregularities, moderate or significant lesions) or absence (normal angiogram) of significant CAD respectively, patients were divided into two groups: A (n=127, 48%) and B (n=137, 52%). A mean of 3.5 classical risk factors were identified in men and 2.6 in women. LP (obtained on admission, in the fasting state) included total cholesterol (TC), HDL, triglycerides (TG), LDL, and lipoprotein(a).

Results: With the exception of male gender, diabetes and HDL, the other factors studied - smoking, hypertension, TC, TG, LDL (in both statin-treated and non-statin-treated patients) and lipoprotein(a) - did not show significant differences between groups A and B; LDL was 116 +/- 40mg/dl in group A vs. 123 +/- 38mg/dl in group B, in non-statin-treated patients; significant CAD was identified in 64% of men vs. 26% of women (p < 0.001); 43% of group A had diabetes vs. 27% of group B (p<0.01); HDL was 49 +/- 14mg/dl in group A vs. 59 +/- 16mg/dl in group B (p < 0.001); HDL in group A was 49 +/- 14 mg/dl in men vs. 49 +/- 13 mg/dl in women (NS) and 45 +/- 13 mg/dl in diabetic patients vs. 52 +/- 14 mg/dl in non-diabetics (p <0.02); HDL in group B diabetic patients was 54 +/- 17 mg/dl in men vs. 56 +/- 18 mg/dl in women (NS), and HDL in group B non-diabetic patients was 55 +/- 13mg/dl in men vs. 63 +/- 17 mg/dl in women (p < 0.02). Multivariate analysis showed that only low HDL and diabetes (in women) were independent risk factors for significant CAD. The effect of male gender as a risk factor appears to be exerted mainly through lower HDL levels.

Conclusions: Elevated HDL is the main negative risk factor for significant CAD in elderly high-risk but mildly dyslipidemic CAVD patients. HDL does not appear to have any protective effect in the pathophysiology of CAVD. In terms of long-term intervention, primary prevention of significant CAD should in the future be hybrid, focusing mainly on improving HDL function, but also on lowering LDL.