Evaluation, Treatment, and Outcomes in Patients With Possible Severe Aortic Stenosis

Background Severe aortic stenosis (AS) is associated with significant morbidity and mortality. Prior reports suggest that severe AS is under-recognized and undertreated. Methods Retrospective analysis of the Duke Echocardiography Laboratory Database of individuals undergoing an echocardiogram between 2016 and 2024. Patients with possible severe AS (any of the following: aortic valve area (AVA) <1.0 cm 2 , mean aortic valve gradient ≥40mmHg, peak aortic velocity ≥4.0 m/s) and possible low-gradient severe AS (AVA <1.0cm 2 , aortic gradient <40mmHg and peak velocity of <4m/s) were identified. Individuals were stratified based on stage of cardiac damage. Outcomes of interest included percent of patients receiving appropriate confirmatory testing, aortic valve replacement (AVR), heart failure (HF) hospitalization (total events) and all-cause mortality. Results Of 114,171 unique individuals who underwent echocardiography, 3,220 had possible severe AS. Those with possible low-gradient severe AS (n = 1,764) infrequently underwent confirmatory testing (18.1% at 1-year). Over a median of 1.4 years of follow-up 1,452 (45.1%) underwent AVR. Significant predictors of AVR utilization included age <75, sex, advanced stage of cardiac damage, absence of symptoms, frailty, ordering provider and severity reported in the echocardiogram. AVR was associated with lower one-year mortality (hazard ratio 0.46; 95% CI 0.37 – 0.57). Overall, the population demonstrated a mortality rate of 17.6 per 100 person-years and a HF hospitalization rate of 13.5 per 100 person-years, which were higher in those with advanced cardiac stages and those with possible low-gradient severe AS. Conclusion Patients with possible severe AS represent a high-risk population with substantial variation in confirmatory testing and AVR utilization, including differences across patient characteristics and provider factors.