European Journal of Cardiovascular Medicine

Valvular heart disease (VHD) remains a significant cause of cardiovascular morbidity and mortality worldwide, with its prevalence and etiology varying markedly across regions and socioeconomic strata.[1]In high-income countries, degenerative/calcific valve lesions predominate due to aging populations, whereas in many low- and middle-income countries, rheumatic heart disease (RHD) continues to account for a substantial proportion of cases. [3,5,9] coronary artery disease (CAD) frequently coexists with VHD, especially in elderly and those with degenerative lesions. Its presence significantly influences surgical strategy, often necessitating concomitant coronary artery bypass grafting (CABG), which increases surgical complexity and perioperative risk. Current guidelines from the American College of Cardiology/American Heart Association (ACC/AHA) and European Society of Cardiology (ESC) recommend preoperative coronary angiography (CAG) in selected patients with VHD, particularly in men >40 years, postmenopausal women and symptoms of angina.[7,8] However, these recommendations are largely based on Western populations. Indian patients differ significantly in age at presentation, etiology, and risk factor profile. This study aims to determine the prevalence, angiographic profile, and predictors of CAD in patients undergoing screening CAG prior to valve replacement surgery in a tertiary care centre in India.

This prospective observational study was conducted at a tertiary care cardiology centre in Kasmir, over a period of two years. We included 150 consecutive adults (≥40 years) undergoing preoperative CAG before planned open heart valve replacement surgery. Patients with prior coronary revascularization or known CAD were excluded. Baseline demographic and clinical data were recorded, including major risk factors like hypertension (office BP ≥ 140/90, or on antihypertensive medications), diabetes (fasting glucose ≥126 mg/dl, post-prandial glucose ≥200 mg/dl, HbA1c ≥ 6.5 % or on anti-diabetic medications), dyslipidemia (total cholesterol ≥200 mg/dl, triglycerides ≥150 mg/dl, HDL <40 mg/dl in men or < 50 mg/dl in women, LDL ≥130 mg/dlor current use of lipid lowering medications), smoking, family history of CAD, and history of angina on effort (AOE). Valve lesion etiology was classified as degenerative/calcific, rheumatic, bicuspid aortic valve (BAV), or mitral valve prolapse (MVP) based on transthoracic or transesophageal echocardiograms.

CAG was performed using standard techniques.Procedural details including vascular access route (radial or femoral) and access crossover were noted. Access site choice was at the operator’s discretionguided partly by aortic dimensions on echocardiography. Coronary lesions were visually assessed by two independent cardiologists. Significant CAD was defined as ≥50% diameter stenosis in at least one major epicardial artery. Non-obstructive CAD was defined as <50% stenosis.

Statistical analysis:

Statistical analyses were performed using SPSS Statistics for Windows, Version 25.0 (IBM Corp., Armonk, NY, USA). Continuous variables were expressed as mean ± SD and categorical variables as frequencies and percentages. Associations with CAD were tested using chi-square or t-tests as appropriate. Variables with p<0.10 in univariate analysis were included in multivariable logistic regression to identify independent predictors.

A total of 150 patients were included in the study. Table 1 summarizes the baseline demographic, clinical and etiological characteristics of the study population. The mean age of the study cohort was 60.6 ± 12.1 years, with 66.0% (n=99) males and 34 %  (n=51) females. Degenerative/calcific etiology was the most common (42.0%), followed by rheumatic (32.0%), bicuspid aortic valve (20.0%), and mitral valve prolapse (6.0%). Hypertension was present in 64.0%, smoking in 30.0%, diabetes in 20.0%, dyslipidemia in 18.0%, family history of CAD in 16.0%, and prior typical angina on effort in 34.0% of patients.

Table 1: Baseline characteristics (n=150)

Table 2 shows the use of access site use for angiography.Radial access was used in 68.0%, femoral in 22.0%, and crossover from radial to femoral route occurred in 10.0% of patients.

Table 2: Access site used for CAG

Table 3 shows the findings on coronary angiography. 72.0%of patients had normal coronary arteries. Significant CAD was detected in 22.0% of patients: single-vessel disease in 12.0%, double-vessel disease in 6.0%, and triple-vessel disease in 4.0%. Non-obstructive CAD was present in 6.0%.

Table3: Coronary angiographic findings.

On univariate analysis (Table 4); age ≥60 years, male sex, hypertension, and smoking were associated with CAD. In multivariable logistic regression, age ≥60 years (OR 3.15, 95% CI 1.42–6.97, p=0.004) and male sex (OR 2.40, 95% CI 1.05–5.48, p=0.037) emerged as independent predictors.

Table 4: Predictors of CAD.

Table 5 shows that the distribution of obstructive CA) varied markedly across etiological subgroups. Degenerative/calcific valve disease accounted for the highest burden, with 47.6% demonstrating obstructive CAD. In contrast, patients with rheumatic heart disease (RHD) and mitral valve prolapse (MVP) showed no angiographic evidence of obstructive CAD, while bicuspid aortic valve (BAV) pathology was associated with obstructive CAD in 10% of cases. The association between valve pathology and CAD presence was statistically significant (χ² test, p< 0.0001), underscoring that the likelihood of concomitant CAD is strongly influenced by the underlying valvular etiology. These findings align with the recognized epidemiological pattern wherein degenerative valve lesions, typically occurring in older patients, carry a substantially higher atherosclerotic risk, whereas RHD and MVP are more often observed in younger cohorts with fewer conventional risk factors.

Table 5: Valve etiology and obstructive CAD.

CAD often coexists with VHD, particularly in older patients and in those with degenerative lesions [5,9,12,13]. The coexistence of CAD has important implications for surgical planning, as it may necessitate concomitant coronary artery bypass grafting (CABG) during valve replacement and in addition has unfavourable impact of untreated CAD on short and long term outcomes,thus making identification of CAD necessary. [6,18] International guidelines recommend preoperative coronary angiography in patients with VHD who are at increased risk for CAD, especially those aged over 40 years, males, or those with multiple cardiovascular risk factors[7,8].

In India, the spectrum of VHD reflects a unique transitional epidemiology — while RHD remains common, especially in younger adults, there is a rising burden of degenerative/calcific aortic valve disease in older populations. Indian studies have reported varying prevalence rates of CAD among patients undergoing valve surgery, ranging from 4.9% in RHD to over 20% in degenerative lesions. Predictors such as advanced age, male sex, hypertension, diabetes mellitus, and typical angina have been consistently identified in both Indian and Western cohorts.[4,5,9,10]

Despite these observations, data from India on the prevalence and predictors of CAD in contemporary valve surgery candidates remain limited. Understanding this profile is crucial for optimizing patient selection for preoperative angiography, minimizing unnecessary invasive procedures, and ensuring timely surgical intervention. This study aims to determine the prevalence, angiographic profile, and independent predictors of CAD in patients undergoing screening coronary angiography prior to valve replacement surgery at a tertiary care centre in India.

In this contemporary Indian tertiary care cohort, we found that 22.0% of patients undergoing screening coronary angiography (CAG) prior to valve replacement surgery had significant coronary artery disease (CAD), defined as ≥50% stenosis in at least one major epicardial vessel. This prevalence lies within the range reported in prior reports from the developing countries [5,9,11,12], but is notably lower than Western reports  [14,15], reflecting differences in etiology and patient demographics with a higher prevalence of calcific/degenerative valvular heart disease in western cohorts.

In our study, the predominance of degenerative/calcific etiology in older patients likely explains the higher prevalence of CAD in this subgroup, consistent with the shared risk factor burden and pathophysiological overlap between calcific aortic valve disease and atherosclerosis. Rheumatic valve disease, still prevalent in our population, was associated with lower CAD rates, possibly due to younger age at presentation and differing systemic inflammatory pathways [5,9].

Our multivariable analysis confirmed age ≥60 years and male sex as independent predictors of CAD, mirroring findings from large registries and guideline recommendations [7,8,16]. While hypertension and smoking were more common among CAD patients, their lack of independent association may reflect collinearity with age and sex, as well as sample size limitations.

Procedural insights from our study are relevant for practice. Radial access was feasible in the majority (68%), with a modest 10% crossover rate, highlighting its applicability even in pre-surgical valve patients — a group sometimes perceived as technically challenging due to arterial anatomy, aortic dilatation, or severe valvular calcification. These findings are aligned with recent evidence favoring radial over femoral access for diagnostic angiography in diverse patient populations [17].

The public health implications are significant. As the Indian population ages and degenerative valve disease becomes more prevalent, the proportion of valve surgery candidates with coexistent CAD is expected to rise, increasing the need for integrated surgical strategies and potentially greater use of percutaneous interventions in selected patients.

Limitations:

Limitations include the single-center design, absence of long-term follow-up,and relatively small sample size. Despite these limitations, our study provides updated, procedure-specific epidemiological data for a mixed-etiology Indian valve population and reinforces the value of targeted screening in high-risk subgroups.

In our study cohort of 150 patients undergoing preoperative CAG before valve replacement, significant CAD was present in roughly 22% with age ≥60 year,male sex and presence of degenerative/calcific valve disease emerging as independent predictors;which support targeted preoperative screening in high-risk subgroups to guide operative planning and improve outcomes. The predominance of degenerative over rheumatic valve disease in our cohort mirrors India’s evolving valvular heart disease landscape—where calcific, age‑related valve pathology now predominates, a shift driven by declining RHD rates and increasing life expectancy. Also despite expectations that aortic dilation or unfolding—common in valve diseases - might complicate radial access, our predominantly radial-first approach (in 68% patients) remained highly successful.

Conflict of interest: Nil

Funding: Nil

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