September 3, 2019Journal of the American College of Cardiology
Poor Long-Term Survival in Patients With Moderate Aortic Stenosis
Why the study?
Historical data suggesting poor survival without treatment was largely confined to severe aortic stenosis, leaving the prognostic impact of all levels of native valvular AS to be determined.
Does the presence of moderate or severe aortic stenosis increase the risk of long-term mortality compared to no aortic stenosis?
Structured PICO
Does the presence of moderate or severe aortic stenosis increase the risk of long-term mortality compared to no aortic stenosis?
P
Population
241,303 adults (122,809 males, 118,494 females) with measured aortic valve mean gradient, peak velocity, and/or area, excluding patients with previous aortic valve intervention.
I
Intervention
Presence of mild, moderate, or severe native valvular aortic stenosis (observational exposure).
C
Comparator
No aortic stenosis.
O
Outcome
Long-term mortality (all-cause death) and cardiovascular disease death.hard clinical
Moderate aortic stenosis is associated with a markedly increased risk of long-term mortality (43% at 5 years), challenging the traditional paradigm that only severe aortic stenosis carries a poor prognosis when untreated.
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“We have shown for the first time, in the largest study of aortic stenosis ever undertaken, that aortic stenosis is not a benign disease throughout the spectrum of severity. The current 'watchful waiting' approach to non-severe aortic stenosis mandates serious consideration. Patients in the moderate group of our study had very similar 5-year mortality outcomes to the severe group.”
“These data provide the impetus for a contemporary evaluation of the risk-to-benefit ratio of intervention in the moderate AS population.”
PGPhilippe GénéreuxInterventional cardiologist, Morristown Medical Center
“Not all 20-mm Hg gradient patients are similar. There is a spectrum of moderate AS. You have the mild-moderate, and you have the moderate-severe. It may take 10 years in some cases for it to progress, and in others it may progress rapidly.”
Implication
Raises questions on watchful waiting in moderate AS; leaves open benefit of intervention pending randomized trials.
Abstract
BACKGROUND Historical data suggesting poor survival without treatment is largely confined to severe aortic stenosis (AS). OBJECTIVES To determine the prognostic impact of all levels of native valvular AS. METHODS Severity of AS was characterized by convention and by statistical distribution in 122,809 males (61±17 years) and 118,494 females (62±19 years), with measured Aortic Valve (AV) mean gradient, peak velocity and/or area. The relationship between AS severity and survival were then examined during median 1,198 (IQR 591, 2,166) days of follow-up. Patients with previous aortic valve intervention were excluded. RESULTS Overall, 16,129 (6.7%), 3,315 (1.4%) and 6,383 (2.6%) cases had mild, moderate and severe AS, respectively. On an adjusted basis (versus no AS - 5-year mortality 19%), patients with mild-to-severe AS had an increasing risk of long-term mortality (adjusted hazard ratio 1.44 to 2.09; p<0.001 for all comparisons). 5-year mortality was 43% and 53% in those with moderate AS (mean gradient 20.0 - 39.0 mmHg/peak velocity 3.0 - 3.9 m/s) and severe AS (≥40.0 mmHg, ≥4.0 m/s, or AVA<1.0cm2 in low-flow, low-gradient severe AS). A markedly increased risk of death from all-causes (5-year mortality >50%) and cardiovascular disease was evident from a mean AV gradient >20.0 mmHg (moderate AS) after adjusting for age, sex, left ventricular systolic, diastolic dysfunction, and aortic regurgitation. CONCLUSIONS These unique data confirm that when left untreated, severe AS is associated with poor long-term survival. Moreover, they also suggest poor survival rates in patients with moderate AS.
Discussion
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Cite This Study
Strange et al. (2019) studied this question.