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Societies issue appropriate use criteria for severe aortic stenosis
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Eleven professional societies have published a report to develop and evaluate appropriate use criteria for the treatment of patients with severe aortic stenosis.
The collaboration marks the first appropriate use criteria to address aortic stenosis, as well as the treatment options available for patients.
“There’s been lots of interest on aortic stenosis over the last decade or so, not only because it’s an area of cardiology where there are more imaging techniques and more patients being diagnosed, but of course, we’ve also got new interventions as well,” Robert O. Bonow, MD, MS, MACC, Max and Lilly Goldberg distinguished professor of cardiology and professor of medicine at Northwestern University Feinberg School of Medicine, told Cardiology Today’s Intervention. “Considering all these trends going on in both imaging and diagnosis and treatment, we felt that this was a good time to at least start to begin the discussion as to appropriate use.”
According to a press release from the American College of Cardiology, a writing group of multidisciplinary experts from several CV subspecialties was formed to identify and categorize likely clinical scenarios for patients with severe aortic stenosis. The panelists were asked to rate the scenarios on a scale of 1 to 9, with 1 to 3 classified as being rarely appropriate care, 4 to 6 indicating that it may be appropriate care and 7 to 9 classified as appropriate care. The scoring survey was conducted electronically and the median score was calculated for each separate scenario.
In patients with asymptomatic severe aortic stenosis, the panel found that intervention was appropriate, particularly when associated with a low surgical risk due to this patient group’s increased risk for mortality and indication-driven aortic valve replacement.
When the panel confirmed aortic stenosis to be severe and symptoms were present, AVR was rated appropriate regardless of ejection fraction, flow or gradient. There was, however, an exception when AVR was rated rarely appropriate for patients with left ventricular ejection fraction less than 20%, mean gradian less than 20 mm Hg and no flow reserve who were at intermediate or high surgical risk.
In patients with severe symptomatic aortic stenosis with coexistent unrevascularized stable CAD, transcatheter aortic valve replacement and PCI were rated as appropriate or may be appropriate when patients were at high or intermediate surgical risk or anatomical variations of CAD.
According to the appropriate use criteria, among patients with symptomatic severe aortic stenosis, the rating panel found the option on no interventions on aortic stenosis prior to major urgent or elective surgery due to the risk for perioperative morbidity or mortality to be rarely appropriate. However, balloon valvuloplasty with temporary reduction in degree of stenosis was considered may be appropriate and surgical AVR and TAVR that was considered more definitive was deemed appropriate.
In patients with asymptomatic severe/critical aortic stenosis who required major surgery, more delicate approaches such as no intervention were defined as may be appropriate and AVR was considered appropriate.
According to Bonow, aortic stenosis can occur with multiple presentations, many different severities and severity of other medical conditions, so the appropriate use criteria are a way of beginning a dialogue in which physicians can see how an individual patient might fit into various treatment strategies as designed by a series of experts.
“The whole idea of appropriate use criteria through the methodology developed by the ACC is that we’re saying there’s some options for treating patients which might be very appropriate. We never say it’s not appropriate or inappropriate, we just say there may be situations where it’s less commonly appropriate or rarely appropriate,” Bonow said. “The idea is to create a framework that physicians can use. I think it could be helpful not only to cardiologists, but also for internists who may be diagnosing these patients in the first place.”
In addition to the ACC, the societies contributing to the report were the American Association for Thoracic Surgery, the American Heart Association, the American Society of Echocardiography, the European Association for Cardio-Thoracic Surgery, the Heart Valve Society, the Society of Cardiovascular Anesthesiologists, the Society for Cardiovascular Angiography and Interventions, the Society of Cardiovascular Computed Tomography, the Society for Cardiovascular Magnetic Resonance and the Society of Thoracic Surgeons. − by Dave Quaile
For more information:
Robert O. Bonow, MD, MS, MACC, can be reached at rbonow@nmff.org.
Disclosures: Bonow reports no relevant financial disclosures. Please see the full report for the other authors’ relevant financial disclosures.
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