Hemodynamic Progression and Outcome of Asymptomatic Aortic Stenosis in Primary Care

Abstract

The prognostic relevance of a rapid rate of hemodynamic progression of aortic stenosis (AS) has been predominantly investigated in tertiary centers. We reviewed the clinical and echocardiographic data from 153 asymptomatic patients with AS (age 77 ± 9 years; 65% men), with normal left ventricular function and paired echocardiograms ≥4 months apart (mean 2.9 ± 2.1 years), evaluated in a nonreferral echocardiographic laboratory. The severity of AS was graded by the peak aortic velocity (Vmax) and progression was classified as slow or fast according to a cutoff value of 0.3 m/s increase annually. The end points were all-cause mortality and a composite of all-cause mortality and aortic valve replacement (AVR). At baseline, 135 patients (88%) had mild-to-moderate and 18 (12%) severe AS. Of the 153 patients, 49 (32%) showed fast progression (0.61 ± 0.32 m/s/yr) and 104 (68%) had slow progression (0.10 ± 0.16 m/s/yr). Among the 144 patients (94%) with clinical follow-up data, 40 died and 48 underwent AVR. The mortality rate was greater than that of the general population (p <0.001). On multivariate analysis, the independent predictors of mortality were the yearly change in Vmax (hazard ratio [HR] 13.352 per m/s increase, 95% confidence interval [CI] 5.136 to 34.713, p <0.001) and age (HR 1.122 per year, 95% CI 1.0728 to 1.735, p <0.001). The predictors of the composite end point of death and AVR were the yearly change in Vmax (HR 12.307, 95% CI 6.024 to 25.140, p <0.001) and Vmax on the initial echocardiogram (HR 2.684, 95% CI 1.921 to 3.750, p <0.001). In conclusion, primary care patients with asymptomatic AS are usually elderly and frequently develop rapid hemodynamic progression, which independently predicts, not only AVR, but also overall mortality.

Significance of Coronary Artery Disease and Left Ventricular Afterload in Unoperated Asymptomatic Aortic Stenosis

“…Nistri and colleagues demonstrated that the average increase in Vp was 0.26±0.32 m · s −1 · year −1 with great individual variability in hemodynamic progression. 30 The present study results were consistent with those reports. 2,30 There were few changes over time in LV geometry, mass, and systolic or diastolic function, which is also consistent with a previous study.…”

Current Management of Calcific Aortic Stenosis

“…89-91 Although the current evidence-based guidelines recommend a watchful waiting approach for most asymptomatic patients, numerous studies have shown that patients with severe AS have a high likelihood of developing symptoms and requiring surgery within 3 to 5 years, 6,15,17,18 and other series have reported that asymptomatic patients with severe AS are also at risk of death when managed without surgery. 38,86 As the operative risk of AVR is low in experienced centers, 86,87 there is ongoing interest in identifying high risk asymptomatic patients who might benefit from early, preemptive AVR rather than a watchful waiting approach, as noted previously.…”

“…6,17,18,38 Event-free survival of patients with V max >5 m/sec was 64%, 36%, and 25%, at 1, 2, and 3 years, respectively. 18 Patients with V max >5.5 m/sec developed more severe symptoms, with half presenting with NYHA class III or IV symptoms.…”

“…18 Among patients with severe asymptomatic AS with moderate to severe valve calcification and a rapid increase of V max (>0.3 m/sec in a year), there is a high likelihood of death or onset of symptoms. 15,38 …”

Asymptomatic severe aortic stenosis: challenges in diagnosis and management

“…AS is a chronic and progressive disease, and rapid progression of AS is reported to be related to poor outcomes with asymptomatic AS. The progression rates of AS in previous studies11 32 40 – 43 are shown in table 6. Although there have been many studies of mild-to-moderate AS,11 40–44 data describing the progression rate of severe AS are limited 32.…”