Many patients with severe aortic stenosis untreated years after diagnosis
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Key takeaways:
- Sixty percent of patients with severe symptomatic aortic stenosis underwent valve replacement within 4 years of diagnosis.
- Mortality increased proportionally to aortic stenosis severity.
SAN FRANCISCO — A large, real-world database analysis showed treatment rates for severe symptomatic aortic stenosis are low years after diagnosis, with mortality risk rising with aortic stenosis severity, researchers reported at TCT 2023.
The U.S. data reflect a likely reluctance among cardiologists to intervene in patients when aortic stenosis is considered severe and symptomatic, despite emerging data suggesting even earlier intervention could improve outcomes and reduce mortality, Philippe Généreux, MD, co-director of the Structural Heart Program at Morristown Medical Center, Atlantic Health System, Morristown, New Jersey, told Healio.
“For a long time, we classified patients based on mild, moderate or severe aortic stenosis, and the guidelines for a long time recommended treatment only when it reaches a severe degree,” Généreux said during an interview. “There is growing evidence showing that potentially lesser degree aortic stenosis is associated with mortality, such as moderate aortic stenosis and severe aortic stenosis with no symptoms. There is clearly a shift to being more aggressive with aortic stenosis.”
Large, real-world database
Généreux and colleagues analyzed data from 1,669,536 echocardiographic reports for 1,085,850 patients from 24 U.S. hospitals, using the Egnite database; adults were classified by aortic stenosis severity. Researchers examined untreated mortality and treatment rates, estimating HRs for associations with all-cause mortality.
The findings were simultaneously published in the Journal of the American College of Cardiology.
Among 595,120 patients with an aortic stenosis severity assessment, 11.9% had some degree of stenosis. Among patients with aortic stenosis, 48.9% were classified as mild, 8.2% as mild to moderate, 20.6% as moderate, 5.2% as moderate to severe and 17.1% as severe.
In unadjusted analyses, the Kaplan-Meier-estimated 4-year untreated all-cause mortality rates were the following (P for trend < .0001):
- no aortic stenosis: 13.5% (95% CI, 13.3-13.7);
- mild aortic stenosis: 25% (95% CI, 23.8-26.1);
- mild to moderate aortic stenosis: 29.7% (95% CI, 26.8-32.5);
- moderate aortic stenosis: 33.5% (95% CI, 31-35.8);
- moderate to severe aortic stenosis: 45.7% (95% CI, 37.4-52.8); and
- severe aortic stenosis: 44.9% (95% CI, 39.9-49.6).
Results were similar when adjusted for informative censoring caused by treatment. Kaplan-Meier-estimated 4-year observed treatment rates were 0.2% for none (95% CI, 0.2-0.2), 1% for mild (95% CI, 0.7-1.3), 4.2% for mild to moderate (95% CI, 2-6.3), 11.4% for moderate (95% CI, 9.5-13.3), 36.7% for moderate to severe (95% CI, 31.8-41.2) and 60.7% for severe (95% CI, 58-63.3; P for trend < .0001).
After adjustment, all degrees of aortic stenosis severity were associated with increased mortality compared with none.
“There is clear undertreatment of patients that already meet the class I recommendation for aortic valve replacement, such as severe aortic stenosis with symptoms or low ejection fraction,” Généreux told Healio. “These data are similar to prior smaller studies suggesting at that least 40% if not more patients with class I indications for AVR are not treated, for varying reasons, but this is still very shocking.”
Généreux said the second surprising finding was the number of patients (13.4%) who were classified as having “intermediate” aortic stenosis — nearly one of six patients were labeled as mild to moderate or moderate to severe aortic stenosis, complicating their path to treatment.
“That [number of intermediate diagnoses] is very high and the mortality of those intermediate diagnoses are the same as the higher degree of aortic stenosis severity,” Généreux said. “For me, that is important because it illustrates the difficulty and the challenge in the real world to assess aortic stenosis and classify patients accordingly.”
Undertreatment of patients ‘must be corrected’
In a related editorial published in JACC, Healio | Cardiology Today Editorial Board Member Eugene Braunwald, MD, Distinguished Hersey Professor of Medicine at Harvard Medical School and founding chairman of the TIMI Study Group at Brigham and Women’s Hospital, noted that a key finding in the study was that AVR was carried out in only 36.7% of the moderate to severe aortic stenosis group and 60.7% of the severe aortic stenosis subgroup, calling the percentages of patients not having AVR “excessive” in the era of both surgical and transcatheter AVR.
“This large contemporary database reinforces the position that many patients with aortic stenosis are currently undertreated even in experienced centers, a deficiency that ... must be corrected,” Braunwald wrote.
Braunwald, who was responsible for some of the first referrals for AVR in the early 1960s, wrote the data suggest patients with low-flow, low-gradient severe aortic stenosis, irrespective of the presence of symptoms, may be candidates for AVR as well.
“Because of the concern that chronic pressure overload can result in irreversible myocardial damage, there is growing interest in earlier AVR,” Braunwald wrote. “Thus, asymptomatic patients with moderately severe and severe aortic stenosis at high risk should also be considered.”
References:
- Braunwald E. J Am Coll Cardiol. 2023;doi:10.1016/j.jacc.2023.10.001.
- Généreux P, et al. J Am Coll Cardiol. 2023;doi:10.1016/j.jacc.2023.09.796.
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Généreux P, et al. TCT Innovation III: Innovation in transcatheter aortic valve replacement. Presented at: TCT Scientific Symposium; Oct. 23-26, 2023; San Francisco (hybrid meeting).
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