Atherosclerosis and its various clinical manifestations are now highly predictable and preventable diseases. Dyslipidemia appears to be a necessary cause, and hypertension and cigarette smoking are both powerful and modifiable contributing causes. Health professionals should incorporate cardiovascular risk assessment and risk factor modification within the context of their delivery of personal health services. Such services probably already have contributed to the decline of cardiovascular mortality, and the current levels of risk factors in the United States population indicate that substantial further reduction should be possibly by creating a smoke-free environment by the year 2000 and by implementing the recommendations of the National Cholesterol and High Blood Pressure Education Programs.
All four cardiac valves can be imaged using MRI. Gradient-echo imaging is the preferred mode of imaging. Valvular regurgitation seen as an area of signal loss in the more proximal chamber can be diagnosed with a high degree of accuracy when compared with 2-D Doppler echocardiography and catheterization angiography. Aortic and mitral stenosis can be semiquantitatively diagnosed, but no method for determining valve areas is currently available. Cardiac prosthetic valves can be imaged but appear only as localized signal loss. Prosthetic valve regurgitation can be diagnosed in the same way as native valve regurgitation. At present, MRI, though not a widely used modality, can contribute significantly to the diagnosis of cardiac valve disorders. With the addition of fast magnetic resonance scanning, which can eliminate the need for electrocardiographic gating, it will be possible for patients with cardiac rhythm irregularities to be scanned, thus broadening the base of patients with valve disease who can be diagnosed.
As patients survive to advanced age, they commonly develop degenerative valvular heart disease as well as degenerative diseases of other organ systems. In addition, a reservoir of patients with other forms of valvular heart disease develop progressive symptomatology with advancing age. These patients often present a challenge to the cardiologist in both diagnosis and management. Inasmuch as these patients tolerate cardiovascular surgery less well than their younger counterparts, criteria for surgical intervention may often need modification. Chronologic age must be recognized as but one of many factors affecting physiologic function. Knowledge of aging-related alterations in function must be employed in both diagnostic and therapeutic algorithms. At times, input from other health-care providers who specialize in the care of the elderly may assist in the assessment of these patients. Surgery should be reserved for higher-risk patients who are severely symptomatic or for those in whom severe symptoms are likely to soon develop based on the natural history of the disease process involved. Those less symptomatic elderly patients with otherwise preserved physiologic functions also may be offered valvular surgery. The availability of nonsurgical, albeit at times palliative, techniques to relieve aortic or mitral stenosis provides an alternative therapeutic option to cardiothoracic surgery. Advances in understanding the pathophysiology and medical therapy of heart failure will continue to contribute to an improved quality of life for those for whom only medical options exist.
