Стеноз аортального клапана и острый коронарный синдром. Очевидные ответы на неочевидные вопросы

В статье представлен систематический обзор, посвященный изучению клинических особенностей развития и подходов к диагностике острого коронарного синдрома (ОКС) у пациентов с аортальным стенозом (АС), а также подходов к управлению рисками неблагоприятных событий. Проведен анализ литературы в период с 2000 по 2024 гг. Информация в обзоре в 80 % случаев отражает результаты работ по этому вопросу за последние 5 лет. Основные базы данных, используемые для поиска информации и написания обзора: eLibrary.ru, PubMed, платформы издательств Nature, Springer materials, PLOS (Public Library of Science). Для литературного поиска использовались ключевые слова: аортальный стеноз, инфаркт миокарда, острый коронарный синдром. Всего найдено 105 полнотекстовых источников литературы, для составления тематического обзора использованы 64 литературных источника, наиболее подходящих по тематике обзора. Представлены современные данные о сложностях дифференциальной диагностики декомпенсации АС и ОКС, данные об общем патогенезе развития коронарного атерокальциноза и АС, перспективные алгоритмы хирургического лечения пациентов с сочетанием АС и различных форм ишемической болезни сердца (острых и хронических).

1. Барбараш О.Л., Ляпина И.Н. Современные тенденции в организации помощи пациентам с приобретенными пороками сердца. Кардиологический вестник. 2024;19(4):5-12. DOI: 10.17116/Cardiobulletin2024190415

2. Moreno R, ACP Journal Club Editorial Team at McMaster University. In asymptomatic severe AS, early surgery vs. conservative therapy reduced a composite of death, MI, stroke, or HF hospitalization at 63 mo. Annals of Internal Medicine. 2025;178(1):JC6. DOI: 10.7326/ANNALS-24-03367-JC

3. Takeji Y, Tada H, Taniguchi T, Sakata K, Kitai T, Shirai S et al. Current Management and Therapy of Severe Aortic Stenosis and Future Perspective. Journal of Atherosclerosis and Thrombosis. 2024;31(10):1353–64. DOI: 10.5551/jat.RV22023

4. Aluru JS, Barsouk A, Saginala K, Rawla P, Barsouk A. Valvular Heart Disease Epidemiology. Medical Sciences. 2022;10(2):32. DOI: 10.3390/medsci10020032

5. Медков В.М. Демография. - Ростов-на-Дону: Феникс; 2002. – 448c]. ISBN 5-222-01106-8

6. Messika-Zeitoun D, Baumgartner H, Burwash IG, Vahanian A, Bax J, Pibarot P et al. Unmet needs in valvular heart disease. European Heart Journal. 2023;44(21):1862–73. DOI: 10.1093/eurheartj/ehad121

7. Толпыгина С.Н., Загребельный А.В., Марцевич С.Ю. Прогностическое значение кальцинированного аортального стеноза у пациентов регистра ПРОГНОЗ ИБС. Российский кардиологический журнал. 2022;27(1):42-7. DOI: 10.15829/1560-4071-2022-4836

8. Marangou J, Beaton A, Aliku TO, Nunes MCP, Kangaharan N, Reményi B. Echocardiography in Indigenous Populations and Resource Poor Settings. Heart, Lung and Circulation. 2019;28(9):1427–35. DOI: 10.1016/j.hlc.2019.05.176

9. Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F et al. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease. Journal of the American College of Cardiology. 2021;77(4):e25–197. DOI: 10.1016/j.jacc.2020.11.018

10. Дрень Е.В., Ляпина И.Н., Печерина Т.Б., Барбараш О.Л. Фенотип современного пациента с приобретёнными пороками клапанов сердца: обзор литературы. CardioСоматика. 2023;14(4):269–82. DOI: 10.17816/CS601825

11. Сизов А.В., Зотов Д.Д. Инфаркт миокарда второго типа при выраженном аортальном стенозе. Университетский терапевтический вестник. 2022;4(1):32-6. DOI: 10.56871/5991.2022.32.45.004

12. Iung B, Baron G, Butchart EG, Delahaye F, Gohlke-Bärwolf C, Levang OW et al. A prospective survey of patients with valvular heart disease in Europe: The Euro Heart Survey on Valvular Heart Disease. European Heart Journal. 2003;24(13):1231–43. DOI: 10.1016/ S0195-668X(03)00201-X

13. Iung B, Delgado V, Rosenhek R, Price S, Prendergast B, Wendler O et al. Contemporary Presentation and Management of Valvular Heart Disease: The EURObservational Research Programme Valvular Heart Disease II Survey. Circulation. 2019;140(14):1156–69. DOI: 10.1161/CIRCULATIONAHA.119.041080

14. Карпова Н.Ю., Рашид М.А., Чипигина Н.С., Казакова Т.В., Зудилина А.Э. Кальцинированный аортальный стеноз: известные факты и перспективные исследования. Клиницист. 2020;14(1–2):34–41. DOI: 10.17650/1818-8338-2020-14-1-2-34-41

15. Banovic M, Athithan L, McCann GP. Aortic stenosis and diabetes mellitus: An ominous combination. Diabetes and Vascular Disease Research. 2019;16(4):310–23. DOI: 10.1177/1479164118820657

16. Santangelo G, Bursi F, Faggiano A, Moscardelli S, Simeoli P, Guazzi M et al. The Global Burden of Valvular Heart Disease: From Clinical Epidemiology to Management. Journal of Clinical Medicine. 2023;12(6):2178. DOI: 10.3390/jcm12062178

17. Cubrilo M, Banovic M, Matkovic M, Bilbija I, Aleksic N, Ivanisevic D et al. Incidence and Prognostic Significance of Silent Coronary Disease in Asymptomatic Patients with Severe Aortic Stenosis. Medicina. 2024;60(9):1503. DOI: 10.3390/medicina60091503

18. Andell P, Li X, Martinsson A, Andersson C, Stagmo M, Zöller B et al. Epidemiology of valvular heart disease in a Swedish nationwide hospital-based register study. Heart. 2017;103(21):1696–703. DOI: 10.1136/heartjnl-2016-310894

19. Kearney K, Sigursdsson S, Eiriksdottir G, O’Brien KD, Gudnason V, Owens DS. Abstract 17756: incidence and progression of aortic valve calcification among the elderly: a prospective analysis of the age, geneenvironment susceptibility (AGES)-Reykjavik study. Circulation. 2012;126(Suppl 21):A17756. Av. at: https://www.ahajournals.org/doi/abs/10.1161/circ.126.suppl_21.a17756

20. Patel KP, Michail M, Treibel TA, Rathod K, Jones DA, Ozkor M et al. Coronary Revascularization in Patients Undergoing Aortic Valve Replacement for Severe Aortic Stenosis. JACC: Cardiovascular Interventions. 2021;14(19):2083–96. DOI: 10.1016/j.jcin.2021.07.058

21. Hasdai D, Lev EI, Behar S, Boyko V, Danchin N, Vahanian A et al. Acute coronary syndromes in patients with pre-existing moderate to severe valvular disease of the heart: lessons from the EuroHeart Survey of acute coronary syndromes. European Heart Journal. 2003;24(7):623–9. DOI: 10.1016/S0195-668X(02)00742-X

22. Crimi G, Montalto C, Ferri LA, Piatti L, Bossi I, Morici N et al. Clinical Impact of Valvular Heart Disease in Elderly Patients Admitted for Acute Coronary Syndrome: Insights From the Elderly-ACS 2 Study. Canadian Journal of Cardiology. 2020;36(7):1104–11. DOI: 10.1016/j.cjca.2019.11.014

23. Singh GK, Van Der Bijl P, Goedemans L, Vollema EM, Abou R, Ajmone Marsan N et al. Prevalence of Aortic Valve Stenosis in Patients With ST-Segment Elevation Myocardial Infarction and Effect on Long-Term Outcome. The American Journal of Cardiology. 2021;153:30–5. DOI: 10.1016/j.amjcard.2021.05.012

24. Muzafarova T, Motovska Z. The role of pre-existing left-sided valvular heart disease in the prognosis of patients with acute myocardial infarction. Frontiers in Cardiovascular Medicine. 2024;11:1465723. DOI: 10.3389/fcvm.2024.1465723

25. Patlolla SH, Maqsood MH, Belford PM, Kumar A, Truesdell AG, Shah PB et al. Impact of concomitant aortic stenosis on the management and outcomes of acute myocardial infarction hospitalizations in the United States. American Heart Journal Plus: Cardiology Research and Practice. 2022;23:100217. DOI: 10.1016/j.ahjo.2022.100217

26. Abraham B, Farina JM, Fath A, Abdou M, Elbanna M, Suppah M et al. The impact of moderate aortic stenosis in acute myocardial infarction: A multicenter retrospective study. Catheterization and Cardiovascular Interventions. 2023;102(1):159–65. DOI: 10.1002/ccd.30676

27. Чумакова О.С., Селезнева Н.Д., Евдокимова М.А., Осмоловская В.С., Кочкина М.С., Асейчева О.Ю. и др. Прогностическое значение аортального стеноза у больных, перенесших обострение ишемической болезни сердца. Кардиология. 2011;51(1):23-8

28. Chew NWS, Zhang A, Ong J, Koh S, Kong G, Ho YJ et al. Longterm Prognosis in Patients With Concomitant Acute Coronary Syndrome and Aortic Stenosis. Canadian Journal of Cardiology. 2022;38(8):1220–7. DOI: 10.1016/j.cjca.2022.03.010

29. Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD. Third Universal Definition of Myocardial Infarction. Circulation. 2012;126(16):2020–35. DOI: 10.1161/CIR.0b013e31826e1058

30. Шерашов А.В., Шилова А.С., Першина Е.С., Щекочихин Д.Ю., Свет А.В., Гиляров М.Ю. Инфаркт миокарда без признаков обструктивного атеросклероза коронарных артерий. Кардиология. 2020;60(3):89–95. DOI: 10.18087/cardio.2020.3.n881

31. McConkey HZR, Marber M, Chiribiri A, Pibarot P, Redwood SR, Prendergast BD. Coronary Microcirculation in Aortic Stenosis. Circulation: Cardiovascular Interventions. 2019;12(8):e007547. DOI: 10.1161/CIRCINTERVENTIONS.118.007547

32. Yan AT, Koh M, Chan KK, Guo H, Alter DA, Austin PC et al. Association Between Cardiovascular Risk Factors and Aortic Stenosis. Journal of the American College of Cardiology. 2017;69(12):1523–32. DOI: 10.1016/j.jacc.2017.01.025

33. Deb N, Ali MS, Mathews A, Chang Y-W, Lacerda CM. Shear type and magnitude affect aortic valve endothelial cell morphology, orientation, and differentiation. Experimental Biology and Medicine. 2021;246(21):2278–89. DOI: 10.1177/15353702211023359

34. Ajmone Marsan N, Delgado V, Shah DJ, Pellikka P, Bax JJ, Treibel T et al. Valvular heart disease: shifting the focus to the myocardium. European Heart Journal. 2023;44(1):28–40. DOI: 10.1093/eurheartj/ehac504

35. Scarsini R, Gallinoro E, Ancona MB, Portolan L, Paolisso P, Springhetti P et al. Characterisation of coronary microvascular dysfunction in patients with severe aortic stenosis undergoing TAVI. EuroIntervention. 2024;20(5):e289–300. DOI: 10.4244/EIJ-D-23-00735

36. Alahdab F, Ahmed AI, Nayfeh M, Han Y, Abdelkarim O, Alfawara MS et al. Myocardial Blood Flow Reserve, Microvascular Coronary Health, and Myocardial Remodeling in Patients With Aortic Stenosis. Journal of the American Heart Association. 2024;13(11):e033447. DOI: 10.1161/JAHA.123.033447

37. Belur AD, Solankhi N, Sharma R. Management of coronary artery disease in patients with aortic stenosis in the era of transcatheter aortic valve replacement. Frontiers in Cardiovascular Medicine. 2023;10:1139360. DOI: 10.3389/fcvm.2023.1139360

38. Sellers SL, Gulsin GS, Zaminski D, Bing R, Latib A, Sathananthan J et al. Platelets: Implications in Aortic Valve Stenosis and Bioprosthetic Valve Dysfunction From Pathophysiology to Clinical Care. JACC: Basic to Translational Science. 2021;6(12):1007–20. DOI: 10.1016/j.jacbts.2021.07.008

39. Goldsweig AM, Lotfi A. Beyond Magic: How to Differentiate the Acute Presentations of Aortic Stenosis and Myocardial Infarction? Cardiovascular Revascularization Medicine. 2022;43:18–9. DOI: 10.1016/j.carrev.2022.07.013

40. Patel KP, Chahal A, Mullen MJ, Rathod K, Baumbach A, Lloyd G et al. Acute Decompensated Aortic Stenosis: State of the Art Review. Current Problems in Cardiology. 2023;48(1):101422. DOI: 10.1016/j.cpcardiol.2022.101422

41. Bula K, Ćmiel A, Sejud M, Sobczyk K, Ryszkiewicz S, Szydło K et al. Electrocardiographic criteria for left ventricular hypertrophy in aortic valve stenosis: Correlation with echocardiographic parameters. Annals of Noninvasive Electrocardiology. 2019;24(5):e12645. DOI: 10.1111/anec.12645

42. Комлев А.Е., Блинова Е.В., Сахнова Т.А., Саидова М.А., Имаев Т.Э. Особенности электрокардиограммы в 12 отведениях у пациентов с критическим аортальным стенозом. Российский кардиологический журнал. 2023;28(7):25-31. DOI: 10.15829/1560-4071-2023-5367

43. Heger J, Trimaille A, Kibler M, Marchandot B, Peillex M, Carmona A et al. Electrocardiographic Strain Pattern Is a Major Determinant of Rehospitalization for Heart Failure After Transcatheter Aortic Valve Replacement. Journal of the American Heart Association. 2021;10(3):e014481. DOI: 10.1161/JAHA.119.014481

44. Wald DS, Williams S, Bangash F, Bestwick JP. Watchful Waiting in Aortic Stenosis: The Problem of Acute Decompensation. The American Journal of Medicine. 2018;131(2):173–7. DOI: 10.1016/j.amjmed.2017.08.027

45. Patel KP, Rathod K, Akhtar M, Jones DA, Ozkor M, Kennon S et al. Differentiating Between Acute Decompensated Aortic Stenosis and Myocardial Infarction. Cardiovascular Revascularization Medicine. 2022;43:13–7. DOI: 10.1016/j.carrev.2022.04.003

46. Zern EK, Frank RC, Yucel E. Valvular Heart Disease in the Cardiac Intensive Care Unit. Critical Care Clinics. 2024;40(1):105–20. DOI: 10.1016/j.ccc.2023.05.002

47. Kolte D, Khera S, Vemulapalli S, Dai D, Heo S, Goldsweig AM et al. Outcomes Following Urgent/Emergent Transcatheter Aortic Valve Replacement. JACC: Cardiovascular Interventions. 2018;11(12):1175–85. DOI: 10.1016/j.jcin.2018.03.002

48. Leon MB, Smith CR, Mack M, Miller DC, Moses JW, Svensson LG et al. Transcatheter Aortic-Valve Implantation for Aortic Stenosis in Patients Who Cannot Undergo Surgery. New England Journal of Medicine. 2010;363(17):1597–607. DOI: 10.1056/NEJMoa1008232

49. Piriou P, Manigold T, Letocart V, Le Ruz R, Schurtz G, Vincent F et al. Outcomes of emergency transcatheter aortic valve replacement in patients with cardiogenic shock: A multicenter retrospective study. Cathe terization and Cardiovascular Interventions. 2022;99(7):2117–24. DOI: 10.1002/ccd.30194

50. Goel K, Shah P, Jones BM, Korngold E, Bhardwaj A, Kar B et al. Outcomes of transcatheter aortic valve replacement in patients with cardiogenic shock. European Heart Journal. 2023;44(33):3181–95. DOI: 10.1093/eurheartj/ehad387

51. Prendergast BD, Patterson T, Redwood S. Transcatheter aortic valve implantation in patients with severe aortic stenosis and cardiogenic shock: an important step forward. European Heart Journal. 2023;44(33):3196–8. DOI: 10.1093/eurheartj/ehad471

52. Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J et al. 2021 ESC/EACTS Guidelines for the management of valvular heart disease: Developed by the Task Force for the management of valvular heart disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Revista Española de Cardiología (English Edition). 2022;75(6):524. DOI: 10.1016/j.rec.2022.05.006

53. Paradis J-M, Fried J, Nazif T, Kirtane A, Harjai K, Khalique O et al. Aortic stenosis and coronary artery disease: What do we know? What don’t we know? A comprehensive review of the literature with proposed treatment algorithms. European Heart Journal. 2014;35(31):2069–82. DOI: 10.1093/eurheartj/ehu247

54. Kang D-H, Park S-J, Lee S-A, Lee S, Kim D-H, Kim H-K et al. Early Surgery or Conservative Care for Asymptomatic Aortic Stenosis. New England Journal of Medicine. 2020;382(2):111–9. DOI: 10.1056/NEJMoa1912846

55. Banovic M, Putnik S, Penicka M, Doros G, Deja MA, Kockova R et al. Aortic Valve Replacement Versus Conservative Treatment in Asymptomatic Severe Aortic Stenosis: The AVATAR Trial. Circulation. 2022;145(9):648–58. DOI: 10.1161/CIRCULATIONAHA.121.057639

56. Thompson CR. Acute Coronary Syndrome and Aortic Stenosis: A Lethal Combo! Canadian Journal of Cardiology. 2022;38(8):1130–1. DOI: 10.1016/j.cjca.2022.05.006

57. Муканова М.Б., Копылов Ф.Ю., Комаров Р.Н., Серебренников И.И., Гафуров Ф.С., Хузиахметов А.Н. и др. Острый коронарный синдром у пациентов со стенозом клапана аорты. Практическая медицина. 2023;21(2):73-8. DOI: 10.32000/2072-1757-2023-2-73-78

58. Li S, Liu H, Zhang Y, Zhang M, Zhang H, Zhu C et al. Prognostic role of lipoprotein(a) in atherosclerotic cardiovascular disease risk from a perspective on current risk stratification. MedComm. 2024;5(11):e773. DOI: 10.1002/mco2.773

59. Arsenault BJ, Loganath K, Girard A, Botezatu S, Zheng KH, Tzolos E et al. Lipoprotein(a) and Calcific Aortic Valve Stenosis Progression: A Systematic Review and Meta-Analysis. JAMA Cardiology. 2024;9(9):835–42. DOI: 10.1001/jamacardio.2024.1882

60. Capoulade R, Chan KL, Yeang C, Mathieu P, Bossé Y, Dumesnil JG et al. Oxidized Phospholipids, Lipoprotein(a), and Progression of Calcific Aortic Valve Stenosis. Journal of the American College of Cardiology. 2015;66(11):1236–46. DOI: 10.1016/j.jacc.2015.07.020

61. Capoulade R, Yeang C, Chan KL, Pibarot P, Tsimikas S. Association of Mild to Moderate Aortic Valve Stenosis Progression With Higher Lipoprotein(a) and Oxidized Phospholipid Levels: Secondary Analysis of a Randomized Clinical Trial. JAMA Cardiology. 2018;3(12):1212–7. DOI: 10.1001/jamacardio.2018.3798

62. Kim A-R, Ahn J-M, Kang D-Y, Jun TJ, Sun BJ, Kim HJ et al. Association of Lipoprotein(a) With Severe Degenerative Aortic Valve Stenosis. JACC: Asia. 2024;4(10):751–60. DOI: 10.1016/j.jacasi.2024.07.007

63. Bhatia HS, Ma GS, Taleb A, Wilkinson M, Kahn AM, Cotter B et al. Trends in testing and prevalence of elevated Lp(a) among patients with aortic valve stenosis. Atherosclerosis. 2022;349:144–50. DOI: 10.1016/j.atherosclerosis.2022.01.022

64. Воевода М.И., Ежов М.В., Коновалов Г.А., Железнякова И.А., Покровский С.Н., Алиева А.С. и др. Новые возможности для реальной клинической практики при определении концентрации липопротеина(а) в крови. Резолюция экспертного совета. Русский Медицинский Журнал. 2024;9:40–4. DOI: 10.32364/2225-22822024-9-7