Although adults over the age of 65 are at highest risk for valvular heart disease (VHD), the true prevalence among older Americans is uncertain, as most of the existing data is drawn from studies that lacked diverse populations or were derived from samples of people already seeking medical care.
A new study published in the Journal of the American College of Cardiology now estimates that more than 10 million older adults in the United States have clinically significant VHD, with that number projected to rise to nearly 15 million by 2060. Known as the Age and Sex-Specific Prevalence of Acquired Valvular Heart Disease (PREVUE-VALVE) study, it is one of the largest-scale community-based efforts to estimate VHD in the general population.
“The PREVUE-VALVE study is really designed to answer the question of who out in the community, both among the healthy and unhealthy, has valve disease,” says Michael Brener, M.D., M.S., an interventional cardiologist at NewYork-Presbyterian and Columbia and the first author of the study. “Valvular heart disease is fundamentally a disease of older individuals, so as the population ages, we’re going to have a lot more disease to take care of in the future, and that comes with its challenges.”
A Novel Site-less Design
PREVUE-VALVE was designed as a decentralized, “site-less” study to overcome selection bias and get more accurate, representative population-based estimates of the burden of VHD among adults aged 65 to 85. Rather than recruit participants from the clinic or a hospital setting, the investigators partnered with CVS and Walgreens pharmacies to use their customer databases to recruit the broadest cohort of individuals that represent the general population, says Dr. Brener.
Over 660,000 individuals who filled a prescription were invited to enroll; 3,000 across all 50 states ultimately completed the study, with significant representation from women (57.1%) as well as Black (14.8%) and Hispanic (9.4%) participants. They were visited by trained echocardiographers who obtained a medical history, collected a blood sample, and performed an electrocardiogram (ECG) as well as a complete echocardiogram.
An echocardiogram of a research participant that shows mitral valve regurgitation.
The data was adjudicated by an independent core laboratory at the Cardiovascular Research Foundation, and the findings were then extrapolated to generate population-level estimates with help from the Survey Research Center at the University of Michigan.
The site-less feature of the study was crucial. “It allowed us to move the trial beyond the traditional healthcare infrastructure, enhancing the mobility of study procedures and improving interest,” Dr. Brener says.
The Growing Burden of Valvular Heart Disease
The researchers found the overall prevalence of mild-to-moderate VHD was 18.4%; moderate or greater VHD was 8.2%; and 2.2% had severe disease. “We described mild-to-moderate disease as clinically significant because these individuals, for all intents and purposes, have clinical outcomes that resemble patients with moderate disease,” says Dr. Brener. “This expanded definition more accurately reflects what we observe in clinical settings for symptomatic patients with valvular disease.”
Based on these findings, the investigators estimated that 4.7 million older adults currently have moderate or greater VHD, while 10.6 million have clinically significant VHD. These figures are projected to increase to 6.5 million and 14.7 million, respectively, by 2060.
The study also identified age-related differences in lesion patterns, with the prevalence of tricuspid regurgitation (TR) and aortic stenosis (AS) increasing with age, as well as differences among the sexes. “For men, TR prevalence increases dramatically with age,” says Dr. Brener. “In contrast, women maintain relatively steady rates of TR between ages 65 and 85.”
An Unexpected Finding
TR emerged as the most common lesion, affecting 3.7% of the participants, followed by AS at 3.1%, mitral regurgitation (MR) at 2%, aortic regurgitation (AR) at 0.7%, and mitral stenosis (MS) at 0.1%. Dr. Brener says this was a surprising finding. “The tricuspid valve has often been regarded as the forgotten valve due to the focus on left-sided heart disease, and imaging for the tricuspid valve has traditionally been more challenging,” he adds. “However, with new technologic advances, we are increasingly observing more tricuspid regurgitation in clinical practice, and I believe this trend will continue.”
With new technologic advances, we are increasingly observing more tricuspid regurgitation in clinical practice, and I believe this trend will continue.
— Dr. Michael Brener
The study also found slightly lower rates of valvular disease overall among Black and Hispanic individuals than among white individuals. Among Black participants, the prevalence of any VHD was 54.5% compared with 60% among white participants, driven largely by lower rates of AS and AR. Hispanic participants similarly exhibited a lower prevalence of any VHD (52.7%), driven by lower rates of TR.
The difference in AS prevalence between Black and white patients, however, does not totally account for the current treatment gap that is seen in the lower rates of valve replacement among Black patients. “They are often undertreated for their aortic valve disease, so we still need to improve our efforts to expand access to valvular heart disease care.”
What the Findings Mean for Future Screening and Treatment
The study’s successful in-home echocardiography model could help shape how future cardiac studies are conducted. “This is the first study of its kind and magnitude to identify the epidemiology of a condition without recruiting patients from clinics or hospital settings,” says Dr. Brener. “It has far-reaching implications for the feasibility of conducting research outside of traditional hospital networks.”
Dr. Brener says additional research is needed to determine whether incorporating echocardiograms into routine screenings would be beneficial, and for which patient populations. But what is clear is that the findings serve as a call to action for improved screening and resource planning to deal with the projected patient population.
“It’s evident that we are facing an epidemic of valvular heart disease,” says Dr. Brener. “These numbers could approach 15 million by 2060, and we currently lack the treatment capacity to address many of these lesions. We need to start strategizing on how to align treatment hubs with where patients are located.”
