Prevalence and Prognostic Implications of Discordant Grading and Flow-Gradient Patterns in Moderate Aortic Stenosis

Q: What are the key findings of this study?

Discordant low-gradient moderate AS was independently associated with higher all-cause mortality (HR 1.187), driven by classical (HR 1.710) and paradoxical (HR 1.458) low-flow patterns.

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Moderate aortic stenosis (n=1974). Intervention: Discordant moderate aortic stenosis (MG <20 mm Hg), including normal-flow, paradoxical low-flow, and classical low-flow low-gradient patterns vs. Concordant moderate aortic stenosis (MG ≥20 and <40 mm Hg). Primary outcome: All-cause mortality (HR 1.187, 95% CI 1.006-1.401, p=0.043).

Q: What does this research mean for the field?

In patients with moderate aortic stenosis, discordant grading occurs in 40% of cases, with paradoxical and classical low-flow, low-gradient patterns independently associated with increased all-cause mortality. Novelty: ClaimNovelty.NOVEL_FINDING. Consensus alignment: ConsensusAlignment.NEUTRAL.

Jan Stassen; See Hooi Ewe; Gurpreet K. Singh; Steele C. Butcher; Kensuke Hirasawa; Mohammed Rizwan Amanullah; Stephan Milhorini Pio; Kenny Yoong Kong Sin; Zee Pin Ding; Ching‐Hui Sia; Nicholas Chew; William K F Kong; Kian Keong Poh; Martin B. Leon; Philippe Pîbarot; Victoria Delgado; Nina Ajmone Marsan; Jeroen Joost Bax

doi:10.1016/j.jacc.2022.05.036

August 1, 2022Journal of the American College of CardiologyOpen Access

Prevalence and Prognostic Implications of Discordant Grading and Flow-Gradient Patterns in Moderate Aortic Stenosis

View Full Paper

Ask AI

Bookmark

Share

Key result

Discordant low-gradient moderate AS linked to ~19% higher mortality, driven by low-flow patterns.

HR 1.187
95% CI 1.006-1.401
P=0.043
n=1,974

Why the study?

Although the prognostic implications of discordant grading in severe AS are well known, the prevalence and prognostic implications of different flow-gradient patterns in moderate AS were unknown.

Does discordant low-gradient grading and specific flow-gradient patterns (normal-flow, paradoxical low-flow, and classical low-flow) increase the risk of all-cause mortality compared to concordant grading in patients with moderate aortic stenosis?

Study Design

Type

Cohort (n=1,974)

Multicenter

Yes

Structured PICO

Does discordant low-gradient grading and specific flow-gradient patterns (normal-flow, paradoxical low-flow, and classical low-flow) increase the risk of all-cause mortality compared to concordant grading in patients with moderate aortic stenosis?

P

Population

1,974 adults (mean age 73 years, 49% female) with a first echocardiographic diagnosis of moderate aortic stenosis (AVA 1.0-1.5 cm2) across 3 centers in the Netherlands and Singapore, followed for a median of 50 months.

E

Exposure

Discordant moderate AS (MG <20 mm Hg, n=788), further stratified into 3 flow-gradient patterns: normal-flow, low-gradient (MG <20 mm Hg, SVi ≥35 mL/m2, LVEF ≥50%, n=433); paradoxical low-flow, low-gradient (MG <20 mm Hg, SVi <35 mL/m2, LVEF ≥50%, n=114); and classical low-flow, low-gradient (MG <20 mm Hg, LVEF <50%, n=241).

C

Comparator

Concordant moderate AS (AVA >1.0 and ≤1.5 cm2, MG ≥20 and <40 mm Hg, n=1,186).

O

Outcome

All-cause mortality at a median follow-up of 50 months (IQR: 24-82 months) and up to 5 years, ascertained via hospital records linked to governmental death registries.hard clinical

Main Result

Hazard Ratio: 1.187 (95% CI 1.006–1.401)

Absolute Event Rate: 47% vs 36%

p-value: p=0.043

Discordant grading occurs in 40% of patients with moderate aortic stenosis, and those with classical or paradoxical low-flow, low-gradient patterns face significantly higher mortality, highlighting the need for closer echocardiographic and clinical surveillance.

Limitations

Retrospective study design with potential referral and selection bias for AVR at tertiary referral centers.
Excluded discordant grading with severe AVA (<1.0 cm2) and moderate gradient (20-40 mm Hg), potentially underestimating overall discordant grading prevalence.
Did not use AVA indexed for body surface area due to high obesity prevalence (~25%).
Dobutamine stress echocardiography and CT aortic valve calcium scoring were not systematically performed to confirm AS severity.
Unable to differentiate between cardiac and noncardiac causes of death.
Retrospective analysis of prospectively collected registry data from tertiary referral centers, introducing potential referral and selection bias
Excluded patients with severe AVA (<1.0 cm2) and moderate gradient (20-40 mm Hg)
Did not use indexed AVA to define AS severity due to ~25% obesity prevalence
Dobutamine stress echocardiography and CT aortic valve calcium scoring were not systematically performed
Could not differentiate cardiac vs noncardiac mortality

Ask about this paper

Answers are grounded in this paper and cite their sources.

Implication

May support closer surveillance for low-flow moderate AS; extends discordant grading mortality associations from severe to moderate disease.

Abstract

BACKGROUND The prognostic implications of discordant grading in severe aortic stenosis (AS) are well known. However, the prevalence of different flow-gradient patterns and their prognostic implications in moderate AS are unknown. OBJECTIVES The purpose of this study was to investigate the occurrence and prognostic implications of different flow-gradient patterns in patients with moderate AS. METHODS Patients with moderate AS (aortic valve area >1.0 and ≤1.5 cm2) were identified and divided in 4 groups based on transvalvular mean gradient (MG), stroke volume index (SVi), and left ventricular ejection fraction (LVEF): concordant moderate AS (MG ≥20 mm Hg) and discordant moderate AS including 3 subgroups: normal-flow, low-gradient moderate AS (MG <20 mm Hg, SVi ≥35 mL/m2, and LVEF ≥50%); "paradoxical" low-flow, low-gradient moderate AS (MG <20 mm Hg, SVi <35 mL/m2, and LVEF ≥50%) and "classical" low-flow, low-gradient moderate AS (MG <20 mm Hg and LVEF <50%). The primary endpoint was all-cause mortality. RESULTS Of 1,974 patients (age 73 ± 10 years, 51% men) with moderate AS, 788 (40%) had discordant grading, and these patients showed significantly higher mortality rates than patients with concordant moderate AS (P < 0.001). On multivariable analysis, "paradoxical" low-flow, low-gradient (HR: 1.458; 95% CI: 1.072-1.983; P = 0.014) and "classical" low-flow, low-gradient (HR: 1.710; 95% CI: 1.270-2.303; P < 0.001) patterns but not the normal-flow, low-gradient moderate AS pattern were independently associated with all-cause mortality. CONCLUSIONS Discordant grading is frequently (40%) observed in patients with moderate AS. Low-flow, low-gradient patterns account for an important proportion of the discordant cases and are associated with increased mortality. These findings underline the need for better phenotyping patients with discordant moderate AS.

Discussion

No takes yet. Share an insight, caveat, or question.

Cite This Study

Stassen et al. (2022) conducted a cohort in Moderate aortic stenosis (n=1,974). Discordant moderate aortic stenosis (MG <20 mm Hg), including normal-flow, paradoxical low-flow, and classical low-flow low-gradient patterns vs. Concordant moderate aortic stenosis (MG ≥20 and <40 mm Hg) was evaluated on All-cause mortality (HR 1.187, 95% CI 1.006-1.401, p=0.043). Discordant low-gradient moderate AS was independently associated with higher all-cause mortality (HR 1.187), driven by classical (HR 1.710) and paradoxical (HR 1.458) low-flow patterns.

synapsesocial.com/papers/6af3351fd68ca628bae5711c https://doi.org/10.1016/j.jacc.2022.05.036

View Full Paper

Ask AI

Bookmark

Share

Prevalence and Prognostic Implications of Discordant Grading and Flow-Gradient Patterns in Moderate Aortic Stenosis

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Prevalence and Prognostic Implications of Discordant Grading and Flow-Gradient Patterns in Moderate Aortic Stenosis

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Keep reading

Keep reading