Clinical predictors of prognosis in severe aortic stenosis in unoperated patients > or = 75 years of age

Natural history of initially asymptomatic severe aortic stenosis: a one-stage meta-analysis

BACKGROUND

Current guidelines on the management strategy for patients with asymptomatic severe aortic stenosis (AS) remain unclear. This uncertainty stems from the lack of data regarding the natural history of these patients. To address this gap, we performed a systematic review and meta-analysis examining the natural history of asymptomatic severe AS patients receiving conservative treatment.

METHODS

The PubMed, Cochrane, and Embase databases were searched from inception to 24 January 2024 using the keywords "asymptomatic" AND "aortic" AND "stenosis". We included studies examining patients with asymptomatic severe AS. In interventional trials, only data from conservatively managed arms were collected. A one-stage meta-analysis was conducted using individual patient data reconstructed from published Kaplan-Meier curves. Sensitivity analysis was performed for major adverse cardiovascular outcomes in patients who remained asymptomatic throughout follow-up.

RESULTS

A total of 46 studies were included (n = 9545). The median time to the development of symptoms was 1.11 years (95% CI 0.90-1.53). 49.36% (40.85-58.59) of patients who were asymptomatic had suffered a major adverse cardiovascular event by 5 years. The median event-free time for heart failure hospitalization (HFH) was 5.50 years (95% CI 5.14-5.91) with 36.34% (95% CI 33.34-39.41) of patients experiencing an HFH by year 5. By 5 years, 79.81% (95% CI 69.26-88.58) of patients developed symptoms (angina, dyspnoea, syncope and others) and 12.36% (95% CI 10.01-15.22) of patients died of cardiovascular causes. For all-cause mortality, the median survival time was 9.15 years (95% CI 8.50-9.96) with 39.43% (CI 33.41-36.40) of patients dying by 5 years. The median time to AVR was 4.77 years (95% CI 4.39-5.17), with 52.64% (95% CI 49.85-55.48) of patients requiring an AVR by 5 years.

CONCLUSION

Our results reveal poor cardiovascular outcomes for patients with asymptomatic severe AS on conservative treatment. A significant proportion eventually requires an AVR. Further research is needed to determine if early intervention with AVR is more effective than conservative treatment.

Natural History of Asymptomatic Severe Aortic Stenosis and the Association of Early Intervention With Outcomes: A Systematic Review and Meta-analysis

Importance

Whether intervention should be performed in patients with asymptomatic severe aortic stenosis (AS) remains debated.

Objective

To meta-analyze the natural history of asymptomatic severe AS and examine the association of early intervention with survival.

Data Sources

PubMed, Embase, and Cochrane databases were searched from inception to February 1, 2020.

Study Selection

Observational studies of adult patients with asymptomatic severe AS.

Data Extraction and Synthesis

Two investigators independently extracted study and patient characteristics, follow-up time, events, and prognostic indicators of events. Random-effects models were used to derive pooled estimates.

Main Outcomes and Measures

The meta-analysis on natural history was performed on the primary end point of all-cause death occurring during a conservative treatment period, with secondary end points consisting of cardiac death, death due to heart failure, sudden death, development of symptoms, development of an indication for aortic valve intervention, and aortic valve intervention. The primary end point for the meta-analysis of early intervention vs a conservative strategy was all-cause death during long-term follow-up. Finally, meta-analysis was performed on the association of prognostic indicators with the composite of death or aortic valve intervention found in multivariable models.

Results

A total of 29 studies with 4075 patients with 11 901 years of follow-up were included. Pooled rates per 100 patients per year were 4.8 (95% CI, 3.6-6.4) for all-cause death, 3.0 (95% CI, 2.2-4.1) for cardiac death, 2.0 (95% CI, 1.3-3.1) for death due to heart failure, 1.1 (95% CI, 0.6-2.1) for sudden death, 18.1 (95% CI, 12.8-25.4) for an indication for aortic valve intervention, 18.5 (95% CI, 13.4-25.5) for development of symptoms, and 19.2 (95% CI, 15.5-23.8) for aortic valve intervention. Early intervention was associated with a significant reduction in long-term mortality (hazard ratio, 0.38; 95% CI, 0.25-0.58). Factors associated with worse prognosis were severity of AS, low-flow AS, left ventricular damage, and atherosclerotic risk factors.

Conclusions and Relevance

Data from observational studies and a recent randomized clinical trial suggest that many patients with asymptomatic severe AS develop an indication for aortic valve intervention, and their deaths are mostly cardiac but not only sudden. Other end points besides sudden death should be considered during the decision to perform early intervention that are associated with improved survival.

Outcome of adults with asymptomatic severe aortic stenosis

OBJECTIVES

To evaluate clinical and echocardiographic variables that could be used to predict outcomes in patients with asymptomatic severe aortic valve stenosis. Management of asymptomatic severe aortic stenosis is controversial. Because prophylactic surgery may be protective, independent predictors of events that could justify early surgery have been sought.

METHODS

Outpatients (n=133; mean [+/-SD] age, 66.2+/-13.6 years) with isolated severe asymptomatic aortic stenosis but normal left ventricular function and no previous myocardial infarction were followed up prospectively at a tertiary care hospital.

INTERVENTIONS

We use a "wait-for-events" strategy. Clinical and echocardiographic variables were analyzed.

RESULTS

Nineteen patients developed angina; 40, dyspnea; 5, syncope; and 7, sudden death during a mean follow-up period of 3.30+/-1.87 years. Event-free survival was 90.2+/-2.6% at 1 year, 73.4+/-3.9% at 2 years, 70.7+/-4.3% at 3 years, 57.8+/-4.7% at 4 years, 40.3+/-5.0% at 5 years, and 33.3+/-5.2% at 6 years. The mean follow-up period until sudden death (1.32+/-1.11 years) was shorter than that for dyspnea (2.44+/-1.84 years), syncope (2.87+/-1.26 years) and angina (3.03+/-1.68 years). Cox regression analysis disclosed only reduced but within normal limits ejection fraction as independent predictor of total events.

CONCLUSIONS

Management on "wait-for-events" strategy is generally safe. Progressive left ventricular ejection fraction reduction even within normal limits identified patients at high risk for events in whom valve replacement surgery should be considered.

Cardiac surgery in the elderly: indications and management options to optimize outcomes

The elderly have increasingly benefited from the advances in cardiac surgical techniques and perioperative care. Compared to the same procedures in younger patients their operations can be more technically demanding and their level of reserve leaves less margin should complications occur. The importance of using realistic indications for operations with a focus on improving the quality of their lives and of optimal preoperative preparation of patients is emphasized.