Clinical Investigations
Adverse Outcomes in Moderate Aortic Stenosis
The Association of Moderate Aortic Stenosis with Poor Survival Is Modified by Age and Left Ventricular Function: Insights from SHEBAHEART Big Data

https://doi.org/10.1016/j.echo.2021.12.002Get rights and content

Highlights

  • Moderate AS is independently associated with increased risk for long-term mortality.

  • The association of moderate AS with poor survival is modified by age and by LVEF.

  • The association is no longer significant among patients >80 years of age.

  • The association is more pronounced among patients with low LVEFs.

  • Efforts in the field should focus on young patients and those with low LVEFs.

Background

Data on the independent association of moderate aortic stenosis (AS) with excess mortality, even when it does not progress to severe AS, are limited. The aims of this study were to evaluate the association of moderate AS with poor survival and to identify clinically important modifiers of that association.

Methods

Consecutive patients who underwent echocardiographic evaluation between 2007 and 2019 were included. All-cause mortality and cancer data were available for all patients from national registries. Cox regression survival models were applied, with censoring of patients who developed metastatic cancer, developed more than moderate AS, or underwent aortic valve intervention during follow-up.

Results

The study population included 92,622 patients. There were 2,202 patients (2%) with moderate AS, with a median age of 79 years (interquartile range, 70-85 years), of whom 1,254 (57%) were men. During median follow-up of 5 years (interquartile range, 3-8 years), 19,712 patients (21%) died. The cumulative probability of death at 5 years was higher for patients with moderate AS (46% vs 18%, respectively, log-rank P < .001). Propensity score matching analysis (n = 2,896) that included clinical, laboratory, and echocardiographic predictors of poor survival demonstrated that compared with patients with mild or less AS, those with moderate AS were 17% more likely to die (95% CI, 1.04-1.30; P = .007). Moreover, the model showed that the moderate AS–associated risk was ejection fraction and age dependent, with a more pronounced association among nonoctogenarian patients (P for interaction = .001) and those with reduced ejection fractions (P for interaction = .016).

Conclusions

Moderate AS is independently associated with excess mortality, even when it does not progress to severe AS. The associated risk is more pronounced among patients with reduced ejection fractions and those <80 years of age.

Section snippets

Study Population

This was a retrospective cohort study of all adult patients (>18 years of age) evaluated at the Sheba Medical Center between 2007 and 2019 who completed echocardiographic evaluations. It is based on the SHEBAHEART big data registry. Sheba Medical Center is the largest hospital in Israel, with 115,000 admissions per year and 22,000 echocardiographic examinations per year. The echocardiography reports together with the electronic medical records of all patients were the sources for this study.

Results

The final study population included 92,622 patients, of whom 2,202 (2.3%) had moderate AS. In addition, there were 438 patients (0.5%) with mild to moderate AS, 1,369 (1.5%) with mild AS, and 88,613 (95.7%) with trivial or no AS. Compared with patients with mild or less AS, those with moderate AS were different with respect to baseline demographic and echocardiographic parameters (Table 1). The final cohort of patients with moderate AS had a median age of 79 years (IQR, 70-85 years) and

Discussion

This analysis offers several important observations. First, it confirms previous data on how moderate AS is associated with poor survival. Second, by using the largest propensity score analysis to date and by censoring patients in whom AS progressed to severe, it suggests that moderate AS is not a marker but an independent predictor of poor survival even when it does not progress to severe AS. Third and most important, it shows how the association of moderate AS with poor survival is modified

Conclusion

Moderate AS is independently associated with poor survival. The associated risk is more pronounced among patients with reduced ejection fraction (<50%) and nonoctogenarian age (<80 years). Our findings underscore the need for careful clinical and echocardiographic follow in this population and support the need for randomized trials to assess the clinical benefit of aortic valve interventions among patients with reduced LVEFs and nonoctogenarian patients.

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Cited by (5)

Drs Itelman and Vatury contributed equally to this work.

Conflicts of interest: None.

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