Lipid Lowering Treatment in Mild to Moderate Aortic Stenosis Thesis for the Degree of Philosophiae Doctor (Phd)
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FACULTY OF MEDICINE, UNIVERSITY OF OSLO, AND DEPARTMENT OF CARDIOLOGY, OSLO UNIVERSITY HOSPITAL, AKER AND ULLEVÅL, OSLO, NORWAY 2015 Lipid Lowering Treatment in Mild to Moderate Aortic Stenosis Thesis for the Degree of philosophiae doctor (PhD) Anne Bjørhovde Rossebø December 2015 1 Thesis 2015. Anne Bjørhovde Rossebø © Anne Bjørhovde Rossebø, 2016 Series of dissertations submitted to the Faculty of Medicine, University of Oslo ISBN 978-82-8333-245-2 All rights reserved. No part of this publication may be reproduced or transmitted, in any form or by any means, without permission. Cover: Hanne Baadsgaard Utigard Printed in Norway: 07 Media AS – www.07.no CONTENTS ACKNOWLEDGEMENTS ........................................................................................................... 4 LIST OF PAPERS .......................................................................................................................... 7 Paper I .......................................................................................................................................... 7 Paper II......................................................................................................................................... 7 Paper III ....................................................................................................................................... 7 Paper IV ....................................................................................................................................... 7 ABBREVIATIONS ........................................................................................................................ 8 INTRODUCTION ........................................................................................................................ 10 Etiology ..................................................................................................................................... 13 Risk factors............................................................................................................................ 13 Histopathology ...................................................................................................................... 20 Pharmacologic intervention for AS? ................................................................................... 20 Left ventricle hypertrophy.................................................................................................... 21 AIMS OF THE STUDY ............................................................................................................... 22 Hypothesis ................................................................................................................................. 22 General aims .............................................................................................................................. 23 Specific aims ............................................................................................................................. 23 METHODS .................................................................................................................................... 25 Pilot study at Aker University Hospital 1995-97 .................................................................... 25 Main study design and organization ........................................................................................ 28 Study population ....................................................................................................................... 30 Echocardiography ..................................................................................................................... 35 Study treatment ......................................................................................................................... 36 Simvastatin ............................................................................................................................ 37 Ezetimibe ............................................................................................................................... 37 Study treatment safety .......................................................................................................... 38 Study endpoints ......................................................................................................................... 39 Statistical analysis ..................................................................................................................... 41 SUMMARY OF THE RESULTS ................................................................................................ 45 Paper I ........................................................................................................................................ 45 Paper II....................................................................................................................................... 46 Paper III ..................................................................................................................................... 48 Paper IV ..................................................................................................................................... 49 2 Thesis 2015. Anne Bjørhovde Rossebø DISCUSSION ............................................................................................................................... 51 Mild to moderate aortic stenosis .............................................................................................. 51 Lipid lowering therapy in aortic stenosis ................................................................................ 54 Role of left ventricular hypertrophy ........................................................................................ 58 Sudden cardiac death ................................................................................................................ 60 Limitations................................................................................................................................. 61 Future perspectives ................................................................................................................... 62 CONCLUSIONS ........................................................................................................................... 64 REFERENCE LIST ...................................................................................................................... 66 PAPER I-IV…………………………………………………………………………………. 3 Thesis 2015. Anne Bjørhovde Rossebø ACKNOWLEDGEMENTS The present work is based on clinical studies carried out while based at the Division of Cardiology, Aker University Hospital, Oslo, though this hospital was re-organized and closed down ending 2011 as part of a large hospital ‘merger’ in the capital of Norway. Since 2010 my workplace has been at the Department of Cardiology, Oslo University Hospital, Ullevål. The studies were carried out between 1997 and 2010, with the most active phase 2001-2008. The studies were funded by Kardiologisk Forskningsfond, Aker University Hospital February-March 1998; research grant from MSD Norway 1998-2002; research grant as well as funding of the main study from MSP Singapore Company, LLC, Singapore (a partnership between Merck Sharp and Dohme and Shering Plough) 2003-2008; and a PhD research fellow scholarship from South-Eastern Norway Regional Health Authority 2008-2010. First and foremost I would express my gratitude to Professor Terje R. Pedersen at Oslo University Hospital, Ullevål, who has been my principal advisor during the whole process. He introduced me to research in my very early years of internal medicine and cardiology at Aker University Hospital. I will forever have great respect for this international capacity within lipidology and preventive cardiology, who conveyed with scientific clarity, but also sincere kindness, his great knowledge about clinical research. I am indebted to him for including me into his vast international research network, from which my own network could grow. Through our long lasting collaboration I have learnt that planning, getting funding and not the least execution of large multicenter studies more than anything needs patience and endurance in phases of ups and downs. I am grateful for his ‘never ever give up’-attitude which allowed me, despite the unintentional extended time frame, to complete my cardiology training and be a family person along with research. My second advisor, Professor Dan Atar, previous head of the Cardiology Departments at Aker and Ullevål hospitals, has inspired with his dynamic and ever-optimistic attitude to research. 4 Thesis 2015. Anne Bjørhovde Rossebø I will always be grateful to my previous colleges at the Division of Cardiology Aker University Hospital, where the “conception and birth” and actual work of my research took place. A special thanks to my seniors drs Kjetil Steine and Tone Nerdrum, who with good-humored influence and clinical clarity taught me my basic cardiological skills and introduced me to echocardiography and remained inspiring and positive throughout the Aker years. Furthermore I thank study nurse Hege Claussen, for experienced practical research management since the early start of the study as well as for lending an ear to frustrated research fellows every now and then. I will also thank all study patients I have had the pleasure to know personally through many years. To my distinguished colleges collaborating in the SEAS Steering Committee I will always