Prognostic Risk Stratification of Patients with Moderate Aortic Stenosis

Published:November 04, 2020DOI:https://doi.org/10.1016/j.echo.2020.10.012

      Highlights

      • Patients with moderate AS have poorer survival outcomes than the general population.
      • The prognosis is extremely poor in those with LVEF <50% and/or SVI <35 mL/m2.
      • Those with higher E/e′ are at intermediate risk even when LVEF or SVI is preserved.

      Background

      Currently risk stratification of moderate aortic stenosis (AS) is still incipient. The aim of this study was to identify prognostic factors in patients with moderate AS.

      Methods

      The prognosis of patients with moderate AS (1 < aortic valve area ≤ 1.5 cm2) stratified by left ventricular ejection fraction (LVEF; 50%), stroke volume index (SVI; 35 mL/m2), and elevated E/e′ ratio (average, 14) was compared with that of the age- and sex-matched general population.

      Results

      Of 696 patients (median age, 77 years; aortic valve area 1.3 cm2; 57% men), 279 (40%) died during a median follow-up period of 3.4 years. Mortality was higher in patients with moderate AS than reference (mortality ratio, 2.43; 95% CI, 2.17–2.72). LVEF < 50%, SVI < 35 mL/m2, and elevated E/e′ ratio were present in 113 (17%), 54 (8%), and 330 (54%) patients; mortality ratios were 3.89 (95% CI, 3.07–4.85), 6.40 (95% CI, 4.57–8.71), and 2.58 (95% CI, 2.21–3.00), respectively. Even if LVEF or SVI was preserved, the mortality ratio was more than twice than reference (P < .001), but elevated E/e′ ratio could discriminate additional patients at higher risk (hazard ratio [HR], 2.71; 95% CI, 1.88–3.91). Two hundred one patients (29%) underwent aortic valve replacement at a median of 2.3 years after the diagnosis of moderate AS. LVEF < 50% (HR, 2.98; 95% CI, 1.39–6.56), SVI < 35 mL/m2 (HR, 3.34; 95% CI, 1.02–10.90) and elevated E/e′ ratio (HR, 2.73; 95% CI, 1.26–5.94) were all associated with worse prognosis even if aortic valve replacement was performed.

      Conclusions

      In patients with moderate AS, those with decreased LVEF and/or SVI are at high risk. Even if these parameters are preserved, patients with elevated E/e′ ratios are at intermediate risk. Further investigation is warranted to assess whether earlier intervention could improve outcomes and reduced cardiac-related death among patients at high and intermediate risk.

      Keywords

      Abbreviations:

      AS (Aortic stenosis), AVA (Aortic valve area), AVR (Aortic valve replacement), HR (Hazard ratio), IQR (Interquartile range), LV (Left ventricular), LVEF (Left ventricular ejection fraction), MAC (Mitral annular calcification), NT-proBNP (N-terminal pro–B-type natriuretic peptide), SVI (Stroke volume index)
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