Moderate to severe aortic stenosis in heart failure patients tripled mortality risk (HR 3.66 severe AS) and untreated AS resulted in poor long-term survival regardless of HF subtype.
Does the severity of aortic stenosis impact event-free survival from AVR and all-cause death in patients with heart failure?
In patients with heart failure, the presence of moderate, low-gradient, or severe aortic stenosis is associated with significantly worse event-free survival compared to mild atherosclerotic valve disease, highlighting the need for timely intervention.
Abstract Background Aortic valve stenosis (AS) is associated with higher mortality and increased clinical event rates, particularly with impaired left ventricular function. Insights into the impact of AS across the heart failure (HF) spectrum and evaluation of treatment trends are currently lacking. Purpose To determine the impact of AS in HF patients on long-term survival and to investigate treatment trends in AS. Methods This observational study analyzed 9202 HF patients with AS over an 11-year period form a tertiary care center. HF was diagnosed in accordance with current guidelines and AS was graded as mild, moderate, low-gradient (LG) and severe. Data on aortic valve replacement (AVR) was collected form each patient’s billing codes. Long term survival of patients with AS and the impact of AVR was assessed in all HF subtypes. The primary endpoint was event-free survival from AVR and all-cause death. Results Severe AS was present in 1504 patients (16.3%), moderate in 1260 patients (13.7%), and LG AS in 579 (6.3%). The majority of patients had HF with preserved ejection fraction (HFpEF) (73%, n= 6704), followed by HF with mildly reduced ejection fraction (HFmrEF, 12%, n = 1102) and reduced ejection fraction (HFrEF, 15%, n = 1396). HFpEF was the predominant HF subtype in all AS severity grades except in patients with LG AS (n = 258, 45%, p 0.001). The proportion of patients with HFmrEF and HFrEF was highest in LG AS. Severe AS had the worst event-free survival with a 1-year event rate of 64%, followed by LG AS at 45% (Figure 1). The adverse impact of moderate or greater AS remained after adjustment for clinical confounders (severe AS: Hazard ratio (HR): 3.66 and confidence interval (CI) 95 % 3.41-3.93, p 0.001; LG AS: HR: 2.45, CI 95 %: 2.21-2.71, p 0.001; moderate AS: HR 1.49. CI 95 %: 1.37-1.61, p 0.001) with atherosclerotic valve disease as reference. The worse survival of more than moderate AS was independent of the underlying heart failure subtype. Patients with moderate, LG and severe AS not undergoing AVR during the follow-up had poor long-term outcomes (Figure 2). Conclusion Patients with moderate or greater AS have significantly higher mortality risk, irrespective of HF subtype or clinical confounders. Untreated moderate, LG and severe AS were associated with dismal long-term survival outcomes.Figure 1 Figure 2
Heitzinger et al. (2025) studied this question. Moderate to severe aortic stenosis in heart failure patients tripled mortality risk (HR 3.66 severe AS) and untreated AS resulted in poor long-term survival regardless of HF subtype.