Key result
SMuRF-less status in moderate or worse aortic stenosis is linked to ~89% higher major event risk.
Why the study?
A subgroup of aortic stenosis patients without standard modifiable cardiovascular risk factors develops severe aortic stenosis and may have distinct pathophysiology and clinical course.
Does the absence of standard modifiable cardiovascular risk factors (SMuRFs) affect the incidence of adverse cardiovascular outcomes in patients with moderate or worse aortic stenosis?
Cohort (n=315)
No
Does the absence of standard modifiable cardiovascular risk factors (SMuRFs) affect the incidence of adverse cardiovascular outcomes in patients with moderate or worse aortic stenosis?
Effect estimate: aHR 1.89 (95% CI 1.23 - 2.91)
p-value: p=0.006
Patients with moderate or worse aortic stenosis who lack standard modifiable cardiovascular risk factors paradoxically face a higher risk of adverse cardiovascular events compared to those with these risk factors.
May warrant closer monitoring in SMuRF-less moderate-severe AS; observational data leave open causal mechanisms and need for prospective validation.
Background and Purpose Development of aortic stenosis (AS) is commonly associated with standard modifiable cardiovascular risk factors (SMuRFs) which include hypertension, diabetes mellitus, hyperlipidaemia and smoking. However, there is a subgroup of SMuRF-less AS patients that develop severe AS and may possess distinct pathophysiology and clinical course. This study aimed to evaluate the prevalence, clinical characteristics, and outcomes of AS patients with and without SMuRFs. Methods A total of 315 consecutive moderate or worse AS patients, derived from a retrospective echocardiography database at a tertiary medical centre between September 2011 to December 2015, was studied. Patients were stratified based on the presence or absence of SMuRFs and analysed. Results Among 315 moderate or worse AS patients, 44 (14.0%) patients were SMuRF-less. The mean age of SMuRF-less AS patients was 67.3 ± 19.5 years (vs. SMuRF: 73.0 ± 11.6 years, p = 0.066) and 59.1% (n = 26) were female (p = 0.337). SMuRF-less AS patients had lower BMI (p = 0.045), lower prevalence of coronary artery disease (p = 0.039) and anaemia (p = 0.031). Echocardiographic parameters, including LVEF (p = 0.820) and AS severity (p = 0.544), were largely similar. On multivariable analyses, absence of SMuRFs was associated with higher composite outcomes (subsequent heart failure, acute myocardial infarction, acute ischaemic stroke, cardiovascular hospitalisation, and all-cause mortality) (aHR 1.89, 95% CI 1.23 – 2.91, p = 0.006), but not all-cause mortality (aHR 1.30, 95% CI 0.76 – 2.20, p = 0.349), after adjusting for age, female sex, BMI, co-morbidities, left ventricular ejection fraction, aortic valve intervention, and AS severity. Conclusion SMuRF-less AS patients were associated with higher incidence of composite outcomes, with similar all-cause mortality, compared to those with SMuRFs. Further studies are needed to elucidate the residual risks in SMuRF-less AS patients.
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Leow et al. (2025) conducted a cohort in Moderate or worse aortic stenosis (n=315). Absence of standard modifiable cardiovascular risk factors (SMuRF-less) vs. Presence of standard modifiable cardiovascular risk factors (SMuRFs) was evaluated on Composite outcomes (subsequent heart failure, acute myocardial infarction, acute ischaemic stroke, cardiovascular hospitalisation, and all-cause mortality) (aHR 1.89, 95% CI 1.23 - 2.91, p=0.006). Absence of standard modifiable cardiovascular risk factors in patients with moderate or worse aortic stenosis was associated with a higher risk of composite outcomes (aHR 1.89; 95% CI 1.23-2.91; p=0.006).
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