The medically managed patient with severe symptomatic aortic stenosis in the TAVR era: Patient characteristics, reasons for medical management, and quality of shared decision making at heart valve treatment centers

Abstract

BackgroundLittle is known about patients with severe symptomatic aortic stenosis (AS) who receive medical management despite evaluation at a heart valve treatment center.ObjectiveWe identified patient characteristics associated with medical management, physician-reported reasons for selecting medical management, and patients’ perceptions of their involvement and satisfaction with treatment selection.Methods and resultsOf 454 patients evaluated for AS at 9 established heart valve treatment centers from December 12, 2013 to August 19, 2014, we included 407 with severe symptomatic AS. Information was collected using medical record review and survey of patients and treating physicians. Of 407 patients, 212 received transcatheter aortic valve replacement (TAVR), 124 received surgical aortic valve replacement (SAVR), and 71 received medical management (no SAVR/TAVR). Thirty-day predicted mortality was higher in patients receiving TAVR (8.7%) or medical management (9.8%) compared with SAVR (3.4%) (P<0.001). Physician-reported reasons for medical management included patient preference (31.0%), medical futility (19.7%), inoperability/anatomic infeasibility (11.3%), and inadequate vascular access (8.5%). Compared with patients receiving AVR, medically managed patients were less likely to report that they received enough information about the pros and cons of treatment options (P = 0.03), that their physicians involved them in treatment decisions (P<0.001), and that final decisions were the right ones (P<0.001).ConclusionsPatient preference was the most common physician-reported reason for selecting non-invasive AS management, yet patients not undergoing AVR after valve center evaluation reported being less likely to receive sufficient education about treatment options and more likely to feel uncertain about final treatment decisions. Greater attention to shared decision making may improve the experience of care for this vulnerable group of patients.

Shared decision making in older patients with symptomatic severe aortic stenosis: a systematic review

“…Most studies originate in Europe, four in the USA and two in Canada (table 1). Six studies have a qualitative design,20–25 while eight studies have a quantitative one 26–33. The eligible review34 included both quantitative and qualitative studies.…”

“…The eligible review34 included both quantitative and qualitative studies. The majority of studies focused solely on decision making in TAVR20–25 31 while three studies focused on decision making in all treatment options 26 28 33…”

“…The decision making aspects were divided in decision making experiences20–25 28 34 and treatment decisions 26 27 29–33…”

Bridging gaps in heart valve disease care: Opportunities for quality improvement

“…25,27 Lastly,~1 in 3 patients with symptomatic aortic stenosis would rather medically manage their valve disease than select treatment options because their preferences are usually not aligned with the treatments selected for them. 28 These findings demonstrate that there is an opportunity to improve the care continuum of patients with heart valve disease from identification and management to selection of treatment. Based on this environmental scan, there are no major national or regional quality improvement initiatives targeting heart valve disease identification and management.…”

“…Furthermore, evidence shows that a large proportion of heart murmurs, which often serve as a primary diagnosis for heart valve disease, are often missed by primary care . Lastly, ~1 in 3 patients with symptomatic aortic stenosis would rather medically manage their valve disease than select treatment options because their preferences are usually not aligned with the treatments selected for them . These findings demonstrate that there is an opportunity to improve the care continuum of patients with heart valve disease from identification and management to selection of treatment.…”