Aged; Aortic Valve/diagnostic imaging; Aortic Valve Stenosis/complications/diagnosis/mortality; Cause of Death/trends; Death, Sudden/epidemiology/etiology; Echocardiography; Europe/epidemiology; Female; Follow-Up Studies; Humans; Male; Outpatients; Retrospective Studies; Severity of Illness Index; Survival Rate/trends; Time Factors
Abstract :
[en] IMPORTANCE: Modern data regarding incidence and modes of death of patients with aortic stenosis (AS) are restricted to tertiary centers or studies of aortic valve replacement (AVR). OBJECTIVE: To provide new insights into the natural history of outpatients with native AS based on a large regionwide population study with inclusion by all cardiologists regardless of their mode of practice. DESIGN, SETTING, AND PARTICIPANTS: Between May 2016 and December 2017, consecutive outpatients with mild (peak aortic velocity, 2.5-2.9 m/s), moderate (peak aortic velocity, 3-3.9 m/s), and severe (peak aortic velocity, ≥4 m/s) native AS graded by echocardiography were included by 117 cardiologists from the Nord-Pas-de-Calais region in France. Analysis took place between August and November 2020. MAIN OUTCOMES AND MEASURES: Natural history, need for AVR, and survival of patients with AS were followed up. Indications for AVR were based on current guideline recommendations. RESULTS: Among 2703 patients (mean [SD] age, 76.0 [10.8] years; 1260 [46.6%] women), 233 (8.6%) were recruited in a university public hospital, 757 (28%) in nonuniversity public hospitals, and 1713 (63.4%) by cardiologists working in private practice. A total of 1154 patients (42.7%) had mild, 1122 (41.5%) had moderate, and 427 (15.8%) had severe AS. During a median (interquartile range) of 2.1 (1.4-2.7) years, 634 patients underwent AVR and 448 died prior to AVR. Most deaths were cardiovascular (200 [44.7%]), mainly associated with congestive heart failure (101 [22.6%]) or sudden death (60 [13.4%]). Deaths were noncardiovascular in 186 patients (41.5%) and from unknown causes in 62 patients (13.8%). Compared with patients with mild AS, there was increased cardiovascular mortality in those with moderate (hazard ratio, 1.47 [95% CI, 1.07-2.02]) and severe (hazard ratio, 3.66 [95% CI, 2.52-5.31]) AS. The differences remained significant when adjusted for baseline characteristics or in time-dependent analyses considering AS progression. In asymptomatic patients, moderate and mild AS were associated with similar cardiovascular mortality (hazard ratio, 0.99 [95% CI, 0.44-2.21]). CONCLUSIONS AND RELEVANCE: While patients in this study with moderate AS had a slightly higher risk of cardiovascular death than patients with mild AS, this risk was much lower than that observed in patients with severe AS. Moreover, in asymptomatic patients, moderate and mild AS were associated with similar cardiovascular mortality.
Disciplines :
Cardiovascular & respiratory systems
Author, co-author :
Coisne, Augustin; University Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1011- EGID,
Montaigne, David; University Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1011- EGID,
Aghezzaf, Samy; University Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1011- EGID,
Ridon, Hélène; University Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1011- EGID,
Mouton, Stéphanie; University Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1011- EGID,
Richardson, Marjorie; University Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1011- EGID,
Polge, Anne-Sophie; University Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1011- EGID,
LANCELLOTTI, Patrizio ; Centre Hospitalier Universitaire de Liège - CHU > > Service de cardiologie ; Gruppo Villa Maria Care and Research, Maria Cecilia Hospital, Cotignola, Anthea
Bauters, Christophe; University Lille, Inserm, CHU Lille, Institut Pasteur, U1167, Lille, France.
Ross J Jr, Braunwald E. Aortic stenosis. Circulation. 1968; 38 (1)(suppl): 61-67. 4894151
Bohbot Y, Rusinaru D, Delpierre Q, Marechaux S, Tribouilloy C. Risk stratification of severe aortic stenosis with preserved left ventricular ejection fraction using peak aortic jet velocity: an outcome study. Circ Cardiovasc Imaging. 2017; 10 (10): e006760. doi: 10.1161/CIRCIMAGING.117.006760 29021260
Lancellotti P, Magne J, Dulgheru R, Outcomes of patients with asymptomatic aortic stenosis followed up in heart valve clinics. JAMA Cardiol. 2018; 3 (11): 1060-1068. doi: 10.1001/jamacardio.2018.3152 30285058
Gohlke-Bärwolf C, Minners J, Jander N, Natural history of mild and of moderate aortic stenosis-new insights from a large prospective European study. Curr Probl Cardiol. 2013; 38 (9): 365-409. doi: 10.1016/j.cpcardiol.2013.06.003 23972937
Kennedy KD, Nishimura RA, Holmes DR Jr, Bailey KR. Natural history of moderate aortic stenosis. J Am Coll Cardiol. 1991; 17 (2): 313-319. doi: 10.1016/S0735-1097(10)80092-0 1991886
Rosenhek R, Klaar U, Schemper M, Mild and moderate aortic stenosis: natural history and risk stratification by echocardiography. Eur Heart J. 2004; 25 (3): 199-205. doi: 10.1016/j.ehj.2003.12.002 14972419
Pellikka PA, Sarano ME, Nishimura RA, Outcome of 622 adults with asymptomatic, hemodynamically significant aortic stenosis during prolonged follow-up. Circulation. 2005; 111 (24): 3290-3295. doi: 10.1161/CIRCULATIONAHA.104.495903 15956131
Delesalle G, Bohbot Y, Rusinaru D, Delpierre Q, Maréchaux S, Tribouilloy C. Characteristics and prognosis of patients with moderate aortic stenosis and preserved left ventricular ejection fraction. J Am Heart Assoc. 2019; 8 (6): e011036. doi: 10.1161/JAHA.118.011036 30841771
Strange G, Stewart S, Celermajer D,; National Echocardiography Database of Australia contributing sites. Poor long-term survival in patients with moderate aortic stenosis. J Am Coll Cardiol. 2019; 74 (15): 1851-1863. doi: 10.1016/j.jacc.2019.08.004 31491546
Kampaktsis PN, Avgerinos DV, Vavuranakis M. Poor outcomes in patients with moderate aortic stenosis: let's review the data. J Am Coll Cardiol. 2020; 75 (7): 837. doi: 10.1016/j.jacc.2019.10.061 32081290
Lancellotti P, Tribouilloy C, Hagendorff A,; Scientific Document Committee of the European Association of Cardiovascular Imaging. Recommendations for the echocardiographic assessment of native valvular regurgitation: an executive summary from the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging. 2013; 14 (7): 611-644. doi: 10.1093/ehjci/jet105 23733442
Zoghbi WA, Adams D, Bonow RO, Recommendations for Noninvasive evaluation of native valvular regurgitation: a report from the American Society of Echocardiography developed in collaboration with the Society for Cardiovascular Magnetic Resonance. J Am Soc Echocardiogr. 2017; 30 (4): 303-371. doi: 10.1016/j.echo.2017.01.007 28314623
Baumgartner H, Falk V, Bax JJ,; ESC Scientific Document Group. 2017 ESC/EACTS guidelines for the management of valvular heart disease. Eur Heart J. 2017; 38 (36): 2739-2791. doi: 10.1093/eurheartj/ehx391 28886619
Bauters C, Tricot O, Meurice T, Lamblin N; CORONOR Investigators. Long-term risk and predictors of cardiovascular death in stable coronary artery disease: the CORONOR study. Coron Artery Dis. 2017; 28 (8): 636-641. doi: 10.1097/MCA.0000000000000560 28914638
INSERM CépiDc. Accessed August 23, 2021. https://www.cepidc.inserm.fr/
Otto CM, Burwash IG, Legget ME, Prospective study of asymptomatic valvular aortic stenosis: clinical, echocardiographic, and exercise predictors of outcome. Circulation. 1997; 95 (9): 2262-2270. doi: 10.1161/01.CIR.95.9.2262 9142003
Benfari G, Nistri S, Marin F, Excess mortality associated with progression rate in asymptomatic aortic valve stenosis. J Am Soc Echocardiogr. 2021; 34 (3): 237-244. doi: 10.1016/j.echo.2020.11.015 33253813
Otto CM, Nishimura RA, Bonow RO,; Writing Committee Members. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2021; 77 (4): e25-e197. doi: 10.1016/j.jacc.2020.11.018 33342586
Nkomo VT, Gardin JM, Skelton TN, Gottdiener JS, Scott CG, Enriquez-Sarano M. Burden of valvular heart diseases: a population-based study. Lancet. 2006; 368 (9540): 1005-1011. doi: 10.1016/S0140-6736(06)69208-8 16980116
Lindroos M, Kupari M, Heikkilä J, Tilvis R. Prevalence of aortic valve abnormalities in the elderly: an echocardiographic study of a random population sample. J Am Coll Cardiol. 1993; 21 (5): 1220-1225. doi: 10.1016/0735-1097(93)90249-Z 8459080
Rosenhek R, Binder T, Porenta G, Predictors of outcome in severe, asymptomatic aortic stenosis. N Engl J Med. 2000; 343 (9): 611-617. doi: 10.1056/NEJM200008313430903 10965007
Otto CM, Lind BK, Kitzman DW, Gersh BJ, Siscovick DS. Association of aortic-valve sclerosis with cardiovascular mortality and morbidity in the elderly. N Engl J Med. 1999; 341 (3): 142-147. doi: 10.1056/NEJM199907153410302 10403851
Lancellotti P, Vannan MA. Timing of intervention in aortic stenosis. N Engl J Med. 2020; 382 (2): 191-193. doi: 10.1056/NEJMe1914382 31733179
Taniguchi T, Morimoto T, Shiomi H,; CURRENT AS Registry Investigators. Sudden death in patients with severe aortic stenosis: observations from the CURRENT AS Registry. J Am Heart Assoc. 2018; 7 (11): e008397. doi: 10.1161/JAHA.117.008397 29776957
Otto CM. Sudden cardiac death in patients with aortic stenosis: maybe it is not the valve? Heart. 2020; 106 (21): 1624-1626. doi: 10.1136/heartjnl-2020-317339 32788177
Paradis J-M, Fried J, Nazif T, Aortic stenosis and coronary artery disease: what do we know? what don't we know? a comprehensive review of the literature with proposed treatment algorithms. Eur Heart J. 2014; 35 (31): 2069-2082. doi: 10.1093/eurheartj/ehu247 24970334
Kvidal P, Bergström R, Hörte L-G, Ståhle E. Observed and relative survival after aortic valve replacement. J Am Coll Cardiol. 2000; 35 (3): 747-756. doi: 10.1016/S0735-1097(99)00584-7 10716479