A ortic V alve Repl A cemen T versus Conservative Treatment in A symptomatic Seve R e Aortic Stenosis: The AVATAR Trial

Background: Surgical aortic valve replacement (SAVR) represents a class I indication in symptomatic patients with severe aortic stenosis (AS). However, indications for early SAVR in asymptomatic patients with severe AS and normal left ventricular function remain debated. Methods: The Aortic Valve replAcemenT versus conservative treatment in Asymptomatic seveRe aortic stenosis (AVATAR) trial is an investigator-initiated international prospective randomized controlled trial that evaluated the safety and efficacy of early SAVR in the treatment of asymptomatic patients with severe AS, according to common criteria (valve area ≤1 cm 2 with aortic jet velocity >4 m/s or a mean trans-aortic gradient ≥40 mm Hg), and with normal LV function. Negative exercise testing was mandatory for inclusion. The primary hypothesis was that early SAVR would reduce the primary composite endpoint of all-cause death, acute myocardial infarction, stroke or unplanned hospitalization for heart failure, as compared to a conservative strategy according to guidelines. The trial was designed as event-driven to reach a minimum of 35 prespecified events. The study was performed in 9 centers in 7 European countries. Results: Between June 2015 and September 2020, 157 patients (mean age 67 years, 57 % men) were randomly allocated to early surgery (n=78) or conservative treatment (n=79). Follow-up was completed in May 2021. Overall median follow-up was 32 months: 28 months in the early surgery group and 35 months in the conservative treatment group. There was a total of 39 events, 13 in early surgery and 26 in conservative treatment group. In the early surgery group, 72 patients (92.3 %) underwent SAVR with operative mortality of 1.4 %. In an intention-to-treat analysis, patients randomized to early surgery had a significantly lower incidence of primary composite endpoint than those in the conservative arm (HR 0.46, 95 % CI 0.23-0.90, p=0.02). There was no statistical difference in secondary endpoints, including all-cause mortality, first heart failure hospitalizations, major bleeding or thromboembolic complications, but trends were consistent with the primary outcome. Conclusions: In asymptomatic patients with severe AS, early surgery reduced a primary composite of all-cause death, acute myocardial infarction, stroke or unplanned hospitalization for heart failure compared with conservative treatment. This randomized trial provides preliminary support for early SAVR once AS becomes severe, regardless of symptoms.

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Abstract P023: Relationship Between Vitamin D Status and Incidence of Macro-vascular Events in the Veterans Affairs Diabetes Trial (VADT)

Circulation ◽

10.1161/circ.125.suppl_10.ap023 ◽

2012 ◽

Vol 125 (suppl_10) ◽

Author(s):

Jimmy D Alele ◽

Kelly J Hunt ◽

Bruce W Hollis ◽

Deirdre K Luttrell ◽

Louis M Luttrell ◽

...

Keyword(s):

Myocardial Infarction ◽

Heart Failure ◽

Type 2 Diabetes ◽

Vitamin D ◽

Composite Endpoint ◽

Cardiovascular Death ◽

Veterans Affairs ◽

Vitamin D Status ◽

Primary Composite Endpoint

BACKGROUND: Few studies have examined the relationship between vitamin D levels and incident cardiovascular events in large well-characterized type 2 diabetes cohorts. METHODS: We performed prospective analyses to determine associations between vitamin D status and vascular endpoints among 936 Veterans Affairs Diabetes Trial (VADT) participants (mean age 59.7 years; 96.7% male; 40.4% minority). 25 (OH)-vitamin D was measured a median of two years after entry into the VADT study and participants were subsequently followed an average of 3.7 years for outcomes. Cox proportional hazard models were used to calculate hazard ratios (HRs) for macrovascular endpoints in relation to vitamin D quartile. The primary composite endpoint included documented myocardial infarction; stroke; death from cardiovascular causes; new or worsening congestive heart failure; surgical intervention for cardiac, cerebrovascular, or peripheral vascular disease; inoperable coronary artery disease; and amputation for ischemic gangrene. RESULTS: On average VADT participants had high cardiovascular risk at entry into the study: 65.3% of the patients recruited were obese, 38.5% had previously had a vascular event, 78.7% had hypertension and 59.5% were using statins. During follow-up, 17.2%, 5.0%, 5.9%, 2.4% and 6.6% of participants had a primary composite endpoint, myocardial infarction, chronic heart failure, cardiovascular death or all-cause death, respectively. After adjusting for age, minority status, treatment arm and history of prior event, individuals in the lowest quartile of vitamin D (i.e., 1 to 15.9 ng/ml) were at similar risk of the primary composite endpoint [HR=1.26 (95% CI: 0.81, 1.96)], myocardial infarction [HR=1.13 (95% CI: 0.53, 2.42)], congestive heart failure [HR=1.44 (95% CI: 0.67, 3.06)], cardiovascular death [HR=0.86 (95% CI: 0.28, 2.63)], and death from any cause [HR=1.04 (95% CI: 0.53, 2.04)] as individuals in the highest quartile of vitamin D (i.e., 29.9 to 77.2 ng/ml). CONCLUSIONS: These data indicate that vitamin D status had no significant impact on the incidence of macrovascular events in a cohort of high-risk veterans with type 2 diabetes mellitus in which traditional risk factors were managed according to current treatment guidelines. SUPPORT: This work was supported by American Heart Association Grant-in-Aid AHA0755466U and the Research Service of the Charleston SC VA Medical Center.

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Abstract 14482: Apparent Resistant Hypertension is a Marker of Risk: The Atherosclerosis Risk in Communities (ARIC) Study

Circulation ◽

10.1161/circ.142.suppl_3.14482 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Magnus O Wijkman ◽

Marcus Malachias ◽

Brian Claggett ◽

Susan Cheng ◽

Kunihiro Matsushita ◽

...

Keyword(s):

Myocardial Infarction ◽

Heart Failure ◽

Antihypertensive Drug ◽

Resistant Hypertension ◽

Composite Endpoint ◽

Atherosclerosis Risk In Communities ◽

Drug Classes ◽

Atherosclerosis Risk ◽

Aric Study

Introduction: Apparent resistant hypertension (ARH) is a common marker of risk in patients with established cardiovascular disease. We ascertained the prevalence and prognostic significance of ARH in patients without prior cardiovascular disease. Methods: This prospective observational cohort study included 9669 community-based participants without a history of heart failure, myocardial infarction, or stroke, who completed the Atherosclerosis Risk in Communities (ARIC) study visit 4 between 1996-1998. The definition of ARH was blood pressure (BP) above goal (traditional goal <140/90mmHg, more stringent goal <130/80mmHg) despite use of ≥3 antihypertensive drug classes, or any BP with ≥4 antihypertensive drug classes. Participants with controlled hypertension (CH), defined as BP at goal with use of 1-3 antihypertensive drug classes, constituted the reference group. The outcome was a composite endpoint of heart failure, myocardial infarction, stroke, or death. Cox regression models were adjusted for age, sex, race, BMI, heart rate, smoking, eGFR, LDL, HDL, triglycerides, glucose, and diabetes. Results: Applying the traditional BP goal, 154/9669 participants (1.6%) had ARH, and there were 2311 participants with CH (23.9%). Using the more stringent BP goal, 218/9669 participants (2.3%) had ARH, and 1523 participants (15.8 %) had CH. The median follow-up time was 19 years. Apparent resistant hypertension was associated with an increased risk for the composite endpoint (adjusted hazard ratio 1.58 [95% CI 1.32-1.90] with the traditional BP goal, and adjusted hazard ratio 1.51 [95% CI 1.28-1.79] with the more stringent BP goal). Conclusions: Apparent resistant hypertension had a low prevalence but was independently associated with adverse outcome during long term follow-up, compared to controlled hypertension and even compared to uncontrolled hypertension. This was observed for both traditional and more stringent BP goals.

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Exercise testing in patients with asymptomatic moderate or severe aortic stenosis

Heart ◽

10.1136/heartjnl-2018-312939 ◽

2018 ◽

Vol 104 (22) ◽

pp. 1836-1842 ◽

Cited By ~ 24

Author(s):

Sahrai Saeed ◽

Ronak Rajani ◽

Reinhard Seifert ◽

Denise Parkin ◽

John Boyd Chambers

Keyword(s):

Aortic Stenosis ◽

Exercise Testing ◽

Severe Aortic Stenosis ◽

Prognostic Information ◽

Exercise Tests ◽

Serious Adverse Events ◽

Asymptomatic Patients ◽

All Cause Mortality ◽

Exercise Treadmill

ObjectiveTo assess the safety and tolerability of treadmill exercise testing and the association of revealed symptoms with outcome in apparently asymptomatic patients with moderate to severe aortic stenosis (AS).MethodsA retrospective cohort study of 316 patients (age 65±12 years, 67% men) with moderate and severe AS who underwent echocardiography and modified Bruce exercise treadmill tests (ETTs) at a specialist valve clinic. The outcome measures were aortic valve replacement (AVR), all-cause mortality or a composite of AVR and all-cause mortality.ResultsAt baseline, there were 210 (66%) patients with moderate and 106 (34%) with severe AS. There were 264 (83%) events. 234 (74%) patients reached an indication for AVR, 145 (69%) with moderate and 88 (83%) with severe AS (p<0.05). Of the 30 (9%) deaths recoded during follow-up, 20 (67%) were cardiovascular related. In total, 797 exercise tests (mean 2.5±2.1 per patient) were performed. No serious adverse events were observed. The prevalence of revealed symptoms at baseline ETT was 29% (n=91) and was significantly higher in severe AS compared with moderate AS (38%vs23%, p=0.008). Symptoms were revealed in 18%–59% of patients during serial ETT conducted over a follow-up period of 34.9 (SD 35.1) months. The event-free survival at 24 months with revealed symptoms was 46%±4% and without revealed symptoms was 70%±4%.ConclusionsETT in patients with moderate or severe AS is safe and tolerable. Serial exercise testing is useful to reveal symptoms not volunteered on the history and adds incremental prognostic information to baseline testing.

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Transcatheter aortic valve replacement in elderly population. Do we have reliable scores to predict prognosis?

European Heart Journal ◽

10.1093/ehjci/ehaa946.3244 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

N Ribas Barquet ◽

T.G.B Giralt Borrell ◽

G.C.A Caldentey Adrover ◽

R.M.S Millan Segovia ◽

A.S.C Sanchez Carpintero ◽

...

Keyword(s):

High Risk ◽

Conservative Treatment ◽

Aortic Stenosis ◽

Transcatheter Aortic Valve Replacement ◽

Elderly Population ◽

Severe Aortic Stenosis ◽

Transcatheter Aortic Valve ◽

Risk Patients ◽

Geriatric Evaluation

Abstract Background Aortic stenosis (AS) is the most common valvulopathy in the western world and its prevalence is rising due to an ageing population. Transcatheter aortic valve replacement (TAVR) is the procedure of choice for severe AS in intermediate and high-risk patients and for very elderly population. Geriatric evaluation can be crucial to identify those subjects in which TAVR will not provide a prognosis benefit. Purpose The aims of this study were to compare clinical outcomes of patients that were evaluated by a Heart Team and were treated with conservative treatment or by TAVR and to identify geriatric scales that could predict worse prognosis during follow-up. Methods From November 2015 to April 2019, 154 consecutive patients with severe aortic stenosis assessed for suitability of TAVR were included in the analysis. A complete geriatric evaluation were performed at inclusion. Results Seventy-six patients (51%, median age 82.9±0.7) were allocated to medical treatment (MT) and the remainder (n=78, 49%, median age 83.7±0.6) to TAVR. Median follow up period was 17.8±13.8 months. Basal and echocardiographic features were similar in both groups except for Euroscore and geriatric evaluation (table 1). In a multivariate analysis including treatment and geriatric scales, conservative treatment was an independent predictor of all-cause and cardiovascular mortality (HR 3.92, 95% CI 1.47–10.48, p=0.015 and HR 4.12, 95% CI 0.98–17.28, p=0.0023 respectively). TAVR was also a protective factor for cardiovascular hospitalizations (OR 0.21, 95% CI 0.08–0.52, p<0.001). A Lawton scale score <4 was associated with a higher cardiovascular mortality (HR 9.97, 95% CI 1.18–84.42, p=0.0023) and cardiovascular hospitalizations (OR 3.5, 95% CI 1.30–9.43 p<0.0001). None of the other scores were associated to outcomes. Conclusion TAVR confers a survival benefit in the elderly population with severe aortic stenosis compared to conservative treatment. Lawton scale could be a useful tool to identify high risk patients with poorer prognosis during follow-up independently of the therapy performed. Funding Acknowledgement Type of funding source: None

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Asymptomatic Patients with Severe Aortic Stenosis and the Impact of Intervention

Journal of Cardiovascular Development and Disease ◽

10.3390/jcdd8040035 ◽

2021 ◽

Vol 8 (4) ◽

pp. 35

Author(s):

Mevlüt Çelik ◽

Milan Milojevic ◽

Andras P. Durko ◽

Frans B. S. Oei ◽

Edris A. F. Mahtab ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Stenosis ◽

Severe Aortic Stenosis ◽

Survival Rates ◽

Aortic Valve Area ◽

Term Survival ◽

Asymptomatic Patients ◽

History Of ◽

The Impact

Objectives the exact timing of aortic valve replacement (AVR) in asymptomatic patients with severe aortic stenosis (AS) remains a matter of debate. Therefore, we described the natural history of asymptomatic patients with severe AS, and the effect of AVR on long-term survival. Methods: Asymptomatic patients who were found to have severe AS between June 2006 and May 2009 were included. Severe aortic stenosis was defined as peak aortic jet velocity Vmax ≥ 4.0 m/s or aortic valve area (AVA) ≤ 1 cm2. Development of symptoms, the incidence of AVR, and all-cause mortality were assessed. Results: A total of 59 asymptomatic patients with severe AS were followed, with a mean follow-up of 8.9 ± 0.4 years. A total of 51 (86.4%) patients developed AS related symptoms, and subsequently 46 patients underwent AVR. The mean 1-year, 2-year, 5-year, and 10-year overall survival rates were higher in patients receiving AVR compared to those who did not undergo AVR during follow-up (100%, 93.5%, 89.1%, and 69.4%, versus 92.3%, 84.6%, 65.8%, and 28.2%, respectively; p < 0.001). Asymptomatic patients with severe AS receiving AVR during follow-up showed an incremental benefit in survival of up to 31.9 months compared to conservatively managed patients (p = 0.002). Conclusions: The majority of asymptomatic patients turn symptomatic during follow-up. AVR during follow-up is associated with better survival in asymptomatic severe AS patients.

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Time to percutaneous coronary intervention in patients with ST-elevation myocardial infarction undergoing successful systemic fibrinolysis: does early or late make a difference?

European Heart Journal Acute Cardiovascular Care ◽

10.1093/ehjacc/zuab020.119 ◽

2021 ◽

Vol 10 (Supplement_1) ◽

Author(s):

C Jackson-Pedroza ◽

A Gallardo-Grajeda ◽

C Dattoli-Alejo ◽

R Gopar-Nieto ◽

D Alfaro-Ponce ◽

...

Keyword(s):

Myocardial Infarction ◽

Heart Failure ◽

Congestive Heart Failure ◽

Percutaneous Coronary Intervention ◽

Composite Endpoint ◽

Coronary Intervention ◽

Cardiovascular Death ◽

Primary Composite Endpoint ◽

Percutaneous Coronary ◽

Reduced Risk

Abstract Funding Acknowledgements Type of funding sources: None. OnBehalf PHASE-MX Background/Introduction: Early routine angiography with subsequent Percutaneous Coronary Intervention (PCI) (if needed) after fibrinolysis reduced the rates of reinfarction and recurrent ischemia compared with a ‘watchful waiting’ strategy. A crucial issue is the optimal time delay between successful lysis and PCI, there is a wide variation in delay in trials from a median of 1.3 h to 17h (CAPITAL AMI, GRACIA-1 and STREAM trials). At present a time window of 2-24h after successful lysis is recommended. Purpose To analyze the incidence of major cardiovascular outcomes in patients with ST-segment elevation myocardial infarction (STEMI) according to the timing of PCI after lysis (pharmacoinvasive strategy, less/more than 24h). Methods A retrospective analysis of the PHASE-MX study (ClinicalTrials.gov Identifier: NCT03974581) including patients with STEMI whom underwent pharmacoinvasive strategy during the first 12h since symptom onset. Patients were further stratified according to the time from the use of fibrinolysis to sheat insertion (<24h or >24h) in the completion of pharmacoinvasive strategy. The primary composite endpoint included the occurrence of cardiovascular death, cardiogenic shock, recurrent myocardial infarction or congestive heart failure at 30 days of follow-up. Results A total of 171 patients were included, of whom 34 underwent PCI after fibrinolysis in less than 24 hours and 137 underwent PCI in more than 24 hours (95% CI 24-120h). Mostly were male (86.4%), mean age was 56.4 ±12.1 years. The primary composite endpoint occurred in 2 patients (5.8%) in PCI < 24 hours and 12 patients (8.6%) in PCI >24 hours (p 0.58). PCI in <24h after lysis was not associated with a reduced risk of the primary endpoint (HR 0.66 95%CI: 0.14-2.97). Conclusion In patients with successful fibrinolysis undergoing to PCI the first 24 h was not associated with a reduced risk of cardiovascular death, cardiogenic shock, recurrent MI or congestive heart failure at 30 days comparing with PCI after 24 h. Abstract Figure. Kaplan-Meier in primary endpoint

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Contemporary issues in severe aortic stenosis: review of current and future strategies from the Contemporary Outcomes after Surgery and Medical Treatment in Patients with Severe Aortic Stenosis registry

Heart ◽

10.1136/heartjnl-2019-315672 ◽

2020 ◽

Vol 106 (11) ◽

pp. 802-809 ◽

Cited By ~ 2

Author(s):

Tomohiko Taniguchi ◽

Takeshi Morimoto ◽

Yasuaki Takeji ◽

Takao Kato ◽

Takeshi Kimura

Keyword(s):

Aortic Valve ◽

Aortic Stenosis ◽

Aortic Valve Replacement ◽

Medical Treatment ◽

Clinical Outcomes ◽

Valve Replacement ◽

Severe Aortic Stenosis ◽

Conservative Strategy ◽

Asymptomatic Patients

Contemporary Outcomes after Surgery and Medical Treatment in Patients with Severe Aortic Stenosis (CURRENT AS) registry was a large Japanese multicentre retrospective registry of consecutive patients with severe aortic stenosis (AS) before introduction of transcatheter aortic valve implantation. We sought to overview the data from the CURRENT AS registry to discuss the three major contemporary issues related to clinical practice in patients with severe AS: (1) under-referral/underuse of surgical aortic valve replacement (SAVR) in symptomatic patients with severe AS, (2) management of asymptomatic patients with severe AS and (3) management of patients with low-gradient severe aortic stenosis (LG-AS). First, despite the dismal prognosis of symptomatic patients with severe AS, SAVR, including those performed during follow-up, was reported to be underused. In the CURRENT AS registry, overall 53% of symptomatic patients underwent aortic valve replacement (AVR) during follow-up. Second, we reported that compared with conservative strategy, initial AVR strategy was associated with lower risk of all-cause death and heart failure hospitalisation in asymptomatic patients with severe AS. Although current recommendations for AVR are mainly dependent on the patient symptoms, some patients may not complain of any symptom because of their sedentary lifestyle. We also reported several important objective factors associated with worse clinical outcomes in asymptomatic patients with severe AS for risk stratification. Finally, initial AVR strategy was associated with better long-term clinical outcomes than conservative strategy in both patients with high-gradient AS and patients with LG-AS. The favourable effect of initial AVR strategy was also seen in patients with LG-AS with left ventricular ejection fraction of ≥50%.

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Comparison of Prasugrel and Ticagrelor for Patients with Acute Coronary Syndrome: A Systematic Review and Meta-analysis

Cardiology ◽

10.1159/000520673 ◽

2021 ◽

Author(s):

Lucas Chun Wah Fong ◽

Nicholas Ho Cheung Lee ◽

Andrew T. Yan ◽

Ming-Yen Ng

Keyword(s):

Myocardial Infarction ◽

Meta Analysis ◽

Composite Endpoint ◽

Cardiovascular Death ◽

Weighted Mean ◽

Coronary Syndrome ◽

Primary Composite Endpoint ◽

Significant Difference

Introduction: There has been inconsistent data on the direct comparison of prasugrel and ticagrelor. This meta-analysis was conducted to summarise the current available evidence. Methods: We performed a meta-analysis (PROSPERO-registered CRD42020166810) of randomized trials up to Feb 2020 that compared prasugrel and ticagrelor in acute coronary syndrome with respect to the composite endpoint of myocardial infarction (MI), stroke or cardiovascular death, and secondary endpoints including MI, stroke, cardiovascular death, major bleeding (Bleeding Academic Research Consortium (BARC) type 2 or above), stent thrombosis, all-cause death and other safety outcomes. Results: Of the 11 eligible RCTs with 6098 patients randomized to prasugrel (n=3050) or ticagrelor (n=3048), 180 and 207 had the composite endpoint events in the prasugrel arm and the ticagrelor arm respectively over a weighted mean follow up period of 11±2 months. Compared with prasugrel, the ticagrelor group had similar risk in the primary composite endpoint (Risk Ratio (RR)= 1.17; 95% CI=0.96-1.42; p=0.12, I2=0%). Compared to prasugrel, there was no significant difference associated with the use of ticagrelor groups with respect to stroke (RR=1.05; 95% CI=0.66-1.67; p=0.84, I2=0%); cardiovascular death (RR=1.01; 95% CI=0.75-1.36; p=0.95, I2=0%); BARC type 2 or above bleeding (RR=1.16; 95% CI =0.89-1.52; p=0.26, I2=0%); stent thrombosis (RR=1.58; 95% CI =0.90-2.76; p=0.11, I2=0%); all cause death (RR=1.10; 95% CI =0.86-1.43; p=0.45, I2=0%) except MI (RR=1.38; 95% CI=1.05-1.81; p=0.02, I2=0%) Conclusion: Compared with prasugrel, ticagrelor did not reduce the primary composite endpoint of MI, stroke and cardiovascular death at a weighted mean follow up of 11 months. There was no significant difference between the secondary outcomes except myocardial infarction.

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P3371Impact of severe aortic stenosis on layer-specific longitudinal strain and its prognostic value

European Heart Journal ◽

10.1093/eurheartj/ehz745.0247 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

F Ilardi ◽

R E Dulgheru ◽

S Marchetta ◽

S Cimino ◽

G D'Amico ◽

...

Keyword(s):

Aortic Stenosis ◽

Longitudinal Strain ◽

Severe Aortic Stenosis ◽

Myocardial Dysfunction ◽

Global Longitudinal Strain ◽

Left Atrial Volume ◽

Multivariable Logistic Regression Analysis ◽

Asymptomatic Patients ◽

Myocardial Layers

Abstract Background Global longitudinal strain (GLS) was used to detect early myocardial dysfunction in patients with aortic stenosis (AS), however few data are currently available on the different susceptibility of specific myocardial layer to increased wall stress and its prognostic role. The present study sought to investigate the relationship between changes in LV multilayer strain and the clinical outcome of patients with severe AS and preserved left ventricle ejection fraction (LVEF). Methods We included in the analysis 211 patients (56% males, mean age 73±12 years old) with severe AS and LVEF≥50%, divided in symptomatic (n=114) and asymptomatic group (n=97), and 50 controls matched for age and sex. Patients with moderate-to-severe concomitant valvulopathy and inadequate acoustic windows for evaluation by speckle tracking analysis were excluded. Clinical, demographic and resting echocardiographic data were recorded, including quantification of 2D GLS, subendocardial LS and subepicardial LS. Results Symptomatic patients had increased LV wall thickness and LV mass index than asymptomatic ones (p<0.001), higher transaortic mean pressure gradients (48±14 vs 44±13 mmHg, p=0.004), and lower aortic valve areas (0.42±0.09 vs 0.45±0.08 cm2/m2, p<0.017). GLS was significantly lower in patients with AS compared to controls, especially in symptomatic group (17.9±3.4 vs 19.1±3.1 vs 20.7±2.1%, p<0.001 in symptomatic, asymptomatic and control groups respectively) suggesting an early, subtle, myocardial dysfunction. In particular, the analysis of layer-specific myocardial deformation revealed a marked difference in both the subendocardial LS (20.1±4.9 vs 21.7±4.2 vs 23.4±2.5%, p<0.001) and subepicardial LS (15.8±3.1 vs 16.8±2.8 vs 18.3±1.8%, p<0.001). At multivariable logistic regression analysis, subendocardial LS was independently associated to symptoms (OR=1.148, p=0.014), together with indexed left atrial volume (OR=1.035, p=0.007) and LV concentric remodelling (OR=2.429, p=0.031). During a mean follow up of 38 months (IQ range 18–60 months), 12 patients with asymptomatic severe AS had a cardiovascular (CV) death. The presence of a subendocardial LS <22% at baseline was associated with a higher rate of CV events at 3 and 5-year follow-up (19% vs 5% at 3-year follow-up, and 22% vs 8% at 5-year follow-up, respectively; log-rank p=0.044). Conclusion In patients with severe AS, LS impairment involves all myocardial layers and is more prominent in the advanced phases of the disease. In this setting, the subendocardial LS appears to be independently associated to symptoms than subepicardial LS. In asymptomatic patients, a reduced value of subendocardial LS is associated with higher CV mortality at 3- and 5-year follow-up.

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Outcomes in asymptomatic, severe aortic stenosis

PLoS ONE ◽

10.1371/journal.pone.0249610 ◽

2021 ◽

Vol 16 (4) ◽

pp. e0249610

Author(s):

Anette Borger Kvaslerud ◽

Kenan Santic ◽

Amjad Iqbal Hussain ◽

Andreas Auensen ◽

Arnt Fiane ◽

...

Keyword(s):

Coronary Artery Disease ◽

Aortic Valve ◽

Aortic Stenosis ◽

Aortic Valve Replacement ◽

Valve Replacement ◽

Severe Aortic Stenosis ◽

Asymptomatic Patients ◽

History Of ◽

Artery Disease

Background and aim of the study Patients with asymptomatic, severe aortic stenosis are presumed to have a benign prognosis. In this retrospective cohort study, we examined the natural history of contemporary patients advised against aortic valve replacement due to a perceived lack of symptoms. Materials and methods We reviewed the medical records of every patient given the ICD-10-code for aortic stenosis (I35.0) at Oslo University Hospital, Rikshospitalet, between Dec 1st, 2002 and Dec 31st, 2016. Patients who were evaluated by the heart team due to severe aortic stenosis were categorized by treatment strategy. We recorded baseline data, adverse events and survival for the patients characterized as asymptomatic and for 100 age and gender matched patients scheduled for aortic valve replacement. Results Of 2341 patients who were evaluated for aortic valve replacement due to severe aortic stenosis, 114 patients received conservative treatment due to a lack of symptoms. Asymptomatic patients had higher mortality than patients who had aortic valve replacement, log-rank p<0.001 (mean follow-up time: 4.0 (SD: 2.5) years). Survival at 1, 2 and 3 years for the asymptomatic patients was 88%, 75% and 63%, compared with 92%, 83% and 78% in the matched patients scheduled for aortic valve replacement. 28 (25%) of the asymptomatic patients had aortic valve replacement during follow-up. Age, previous history of coronary artery disease and N-terminal pro B-type natriuretic peptide (NT-proBNP) were predictors of mortality and coronary artery disease and NT-proBNP were predictors of 3-year morbidity in asymptomatic patients. Conclusions In this retrospective study, asymptomatic patients with severe aortic stenosis who were advised against surgery had significantly higher mortality than patients who had aortic valve replacement.

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