Optimizing the treatment of severe aortic stenosis

][4][5][6][7][8][9][10][11] Reported secular trends of AS incidence remain contradictory and lack quantitative Doppler echocardiographic ascertainment.All adult residents in Olmsted County (MN, USA) diagnosed over 20 years (1997-2016) with incident severe AS (first diagnosis) based on quantitatively defined measures (aortic valve area ≤1 cm 2 , aortic valve area index ≤0.6 cm 2 /m 2 , mean gradient ≥40 mmHg, peak velocity ≥4 m/s, Doppler velocity index ≤0.25)were counted to define trends in incidence, presentation, treatment, and outcome.Incident severe AS was diagnosed in 1069 community residents.The incidence rate was 52 per 100 000 patient-years, slightly higher in males vs. females, and was almost unchanged after age and sex adjustment for the US population, 53 per 100 000 residents/year.Over 20 years, severe AS incidence remained stable (P = .2) but the absolute burden of incident cases markedly increased (P = .0004)due to population growth.Incidence trend differed by sex, being stable in men (incidence rate ratio 0.99, P = .7)but declining in women (incidence rate ratio 0.93, P = .02).Over the study period, AS clinical characteristics remained remarkably stable and AVR performance grew and was more prompt, but undertreatment remained prominent (>40%).Early AVR was associated with survival benefit [adjusted hazard ratio (HR) 0.55, 95% confidence interval (CI) 0.42-0.71,P < .0001].Despite these improvements, overall mortality (3-month 8% and 3-year 36%) was swift, considerable, and unabated (all P ≥ .4)throughout the study.Benfari et al. conclude that over 20 years, the population incidence of severe AS remains stable with increased absolute case burden related to population growth.Despite stable severe AS presentation, AVR performance has grown notably; however, while declining, undertreatment