Interventional cardiology

High aortic stenosis burden should be ‘impetus for action’

Aortic stenosis of any degree is associated with a high burden of premature mortality that warrants early detection and treatment, an Australian review has found.

Published in The Lancet Healthy Longevity, (link) the results come from the University of Notre Dame Australia’s Institute for Health Research team of Professors Simon Stewart, David Playford and Geoffrey Strange. They analysed the National Echo Database of Australia of echocardiograms on native aortic valves of almost 100,000 men and 100,000 women aged 65 years and older. They then linked the Echocardiography to the National Death Index to determine mortality.

The study found that 21% of men and 19% of women had evidence of mild-to-severe aortic stenosis. The five-year mortality in men with normal aortic valves was 32·1% and in women was 26·1%, increasing to 40·9% (mild aortic stenosis) and 52·2% (severe aortic stenosis) in men and to 35·9% (mild aortic stenosis) and 55·3% (severe aortic stenosis) in women.

Overall, aortic stenosis was associated with eight more premature deaths and 32·5 more quality-adjusted life years (QALY) for every 1000 men investigated and 12 premature deaths and 57.5 more QALY lost for women when compared with those without aortic stenosis.

The estimated societal cost of premature mortality associated with aortic stenosis was AU$629 million in men and $735 million in women.

The authors noted that despite the high burden of disability and death there are currently no preventive options for aortic stenosis, and resource-intensive aortic valve replacement surgery was not an option beyond the more severe cases.

“The inexorable ageing of many high-income populations will inevitably impart an increasingly challenging and unsustainable societal burden and health-care expenditure if there is no development and application of pragmatic preventive strategies for key contributors of future costs such as aortic stenosis,” they wrote.

However they said there was an opportunity for managing concurrent heart failure in patients with aortic stenosis case based on promising results with agents such as SGLT2 inhibitors.

“Given the high cost of health-care expenditure for patients with heart failure and the proven cost-effectiveness of readily available medical therapy, there is a compelling argument for alerting an individual’s health-care team of the need for more proactive surveillance and management (including evidence-based heart failure treatments) once mild-to-moderate aortic stenosis has been detected,” they said.

Call for action

An associated commentary (link) said the finding that aortic stenosis of any degree is not benign and negatively affects longevity, should be an “impetus for action”.

It made three suggestions:

  • Improve detection of aortic stenosis at the primary care level by systematic annual cardiac auscultation, especially in people older than 65 years
  • Every patient diagnosed with aortic stenosis, even if only mild or moderate, should be promptly referred for regular follow-up, ideally within a heart valve clinic.
  • Performing aortic valve replacement at an earlier stage of the disease, such as at the stage of asymptomatic severe or even at the stage of moderate aortic stenosis might contribute to reduce the mortality excess.

“The improvement of survival of people living with aortic stenosis will necessarily come from better detection of the disease, personalised follow-up and management in the context of heart valve clinics, and intervention at an earlier stage of the disease, which could be as early as moderate stage disease, depending on the results of the ongoing trials.”

Study co-author Professor David Playford said the findings were not surprising, given their previous studies and awareness of “the grim mortality statistics with any degree of aortic stenosis, but the actual cost of this mortality had not been studied previously”.

“Cardiologists need to be aware that aortic stenosis is not a benign condition at any severity,” he told the limbic.

“Patients need to be actively monitored, with careful follow-up, symptom assessment and repeat echocardiography. Patients with moderate AS should be actively reviewed by a team with expertise in AS management (such as a heart valve team), and patients with severe AS should be referred for valve replacement. Whether moderate AS should undergo valve replacement is not yet clear, but at a bare minimum, close surveillance is required.”

He said the Australian regulatory requirements currently only allow symptomatic patients with severe aortic stenosis to undergo valve replacement, which determined clinician behaviour.

The paper was funded by Edwards LifeSciences, the NHMRC, and the National Heart, Lung, and Blood Institute.

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