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Ishii M, Taniguchi T, Morimoto T, Ogawa H, Masunaga N, Abe M, Yoshikawa Y, Shiomi H, Ando K, Kanamori N, Murata K, Kitai T, Kawase Y, Izumi C, Miyake M, Mitsuoka H, Kato M, Hirano Y, Matsuda S, Nagao K, Inada T, Mabuchi H, Takeuchi Y, Yamane K, Toyofuku M, Minamino-Muta E, Kato T, Inoko M, Ikeda T, Komasa A, Ishii K, Hotta K, Higashitani N, Kato Y, Inuzuka Y, Jinnai T, Morikami Y, Akao M, Minatoya K, Kimura T. Reasons for Choosing Conservative Management in Symptomatic Patients With Severe Aortic Stenosis - Observations From the CURRENT AS Registry. Circ J 2019; 83:1944-1953. [PMID: 31316039 DOI: 10.1253/circj.cj-19-0247] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND There has not been a previous report on the long-term outcomes of those patients who refuse aortic valve replacement (AVR) despite physicians' recommendations.Methods and Results:Among 3,815 consecutive patients with severe aortic stenosis (AS) enrolled in the CURRENT AS registry, the study population comprised 2,005 symptomatic patients, who were subdivided into 3 groups by their treatment strategy and the reasons for conservative strategy (Initial AVR group: n=905; Patient rejection group: n=256; Physician judgment group, n=844). The primary outcome measure was a composite of aortic valve-related death and heart failure hospitalization. Patients in the patient rejection group as compared with those in the physician judgment group were younger, and had less comorbidities, and lower surgical risk scores. The cumulative 5-year incidence of the primary outcome measure in the patient rejection group was markedly higher than that in the initial AVR group, and was similar to that in the physician judgment group (60.7%, 19.0%, and 66.4%, respectively). CONCLUSIONS Patient rejection was the reason for non-referral to AVR in nearly one-quarter of the symptomatic patients with severe AS who were managed conservatively. The dismal outcome in patients who refused AVR was similar to that in patients who were not referred to AVR based on physician judgment despite less comorbidities and lower surgical risk scores in the former than in the latter.
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Affiliation(s)
- Mitsuru Ishii
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | - Tomohiko Taniguchi
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | | | - Hisashi Ogawa
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | - Nobutoyo Masunaga
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | - Mitsuru Abe
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | - Yusuke Yoshikawa
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | - Hiroki Shiomi
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | - Kenji Ando
- Department of Cardiology, Kokura Memorial Hospital
| | | | | | - Takeshi Kitai
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital
| | - Yuichi Kawase
- Department of Cardiovascular Medicine, Kurashiki Central Hospital
| | | | | | - Hirokazu Mitsuoka
- Division of Cardiology, Nara Hospital, Kinki University Faculty of Medicine
| | - Masashi Kato
- Department of Cardiology, Mitsubishi Kyoto Hospital
| | - Yutaka Hirano
- Department of Cardiology, Kindai University Hospital
| | - Shintaro Matsuda
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | - Kazuya Nagao
- Department of Cardiovascular Center, Osaka Red Cross Hospital
| | - Tsukasa Inada
- Department of Cardiovascular Center, Osaka Red Cross Hospital
| | | | | | | | - Mamoru Toyofuku
- Department of Cardiology, Japanese Red Cross Wakayama Medical Center
| | - Eri Minamino-Muta
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | - Takao Kato
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | - Moriaki Inoko
- Cardiovascular Center, The Tazuke Kofukai Medical Research Institute, Kitano Hospital
| | | | - Akihiro Komasa
- Department of Cardiology, Kansai Electric Power Hospital
| | | | - Kozo Hotta
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center
| | | | | | | | | | | | - Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | - Kenji Minatoya
- Department of Cardiovascular Surgery, Kyoto University Graduate School of Medicine
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
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Redfors B, Pibarot P, Gillam LD, Burkhoff D, Bax JJ, Lindman BR, Bonow RO, O'Gara PT, Leon MB, Généreux P. Stress Testing in Asymptomatic Aortic Stenosis. Circulation 2017; 135:1956-1976. [PMID: 28507251 DOI: 10.1161/circulationaha.116.025457] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aortic stenosis is 1 of the most common heart valve diseases among adults. When symptoms develop, prognosis is poor, and current guidelines recommend prompt aortic valve replacement. Depending of the severity of the aortic stenosis and the presence of concomitant heart disease and medical comorbidities, stress testing represents a reasonable strategy to help better risk stratify asymptomatic patients. The present report provides a comprehensive review of the current available data on stress testing in aortic stenosis and subsequently summarizes its potential for guiding the optimal timing of aortic valve replacement.
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Affiliation(s)
- Björn Redfors
- From Clinical Trials Center, Cardiovascular Research Foundation, New York (B.R., D.B., M.B.L., P.G.); Sahlgrenska University Hospital, Gothenburg, Sweden (B.R.); Pulmonary Hypertension and Vascular Biology Research Group, Laval University, Québec, Canada (P.P.); Gagnon Cardiovascular Institute, Morristown Medical Center, NJ (L.D.G., P.G.); Columbia University Medical Center, New York (D.B., M.B.L., P.G.); Leiden University Medical Center, The Netherlands (J.J.B.); Structural Heart and Valve Center, Vanderbilt University Medical Center, Nashville, TN (B.R.L.); Northwestern University Feinberg School of Medicine, Chicago, IL (R.O.B.); Brigham and Women's Hospital, Harvard Medical School, Boston, MA (P.T.O.); and Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Québec, Canada (P.G.)
| | - Philippe Pibarot
- From Clinical Trials Center, Cardiovascular Research Foundation, New York (B.R., D.B., M.B.L., P.G.); Sahlgrenska University Hospital, Gothenburg, Sweden (B.R.); Pulmonary Hypertension and Vascular Biology Research Group, Laval University, Québec, Canada (P.P.); Gagnon Cardiovascular Institute, Morristown Medical Center, NJ (L.D.G., P.G.); Columbia University Medical Center, New York (D.B., M.B.L., P.G.); Leiden University Medical Center, The Netherlands (J.J.B.); Structural Heart and Valve Center, Vanderbilt University Medical Center, Nashville, TN (B.R.L.); Northwestern University Feinberg School of Medicine, Chicago, IL (R.O.B.); Brigham and Women's Hospital, Harvard Medical School, Boston, MA (P.T.O.); and Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Québec, Canada (P.G.)
| | - Linda D Gillam
- From Clinical Trials Center, Cardiovascular Research Foundation, New York (B.R., D.B., M.B.L., P.G.); Sahlgrenska University Hospital, Gothenburg, Sweden (B.R.); Pulmonary Hypertension and Vascular Biology Research Group, Laval University, Québec, Canada (P.P.); Gagnon Cardiovascular Institute, Morristown Medical Center, NJ (L.D.G., P.G.); Columbia University Medical Center, New York (D.B., M.B.L., P.G.); Leiden University Medical Center, The Netherlands (J.J.B.); Structural Heart and Valve Center, Vanderbilt University Medical Center, Nashville, TN (B.R.L.); Northwestern University Feinberg School of Medicine, Chicago, IL (R.O.B.); Brigham and Women's Hospital, Harvard Medical School, Boston, MA (P.T.O.); and Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Québec, Canada (P.G.)
| | - Daniel Burkhoff
- From Clinical Trials Center, Cardiovascular Research Foundation, New York (B.R., D.B., M.B.L., P.G.); Sahlgrenska University Hospital, Gothenburg, Sweden (B.R.); Pulmonary Hypertension and Vascular Biology Research Group, Laval University, Québec, Canada (P.P.); Gagnon Cardiovascular Institute, Morristown Medical Center, NJ (L.D.G., P.G.); Columbia University Medical Center, New York (D.B., M.B.L., P.G.); Leiden University Medical Center, The Netherlands (J.J.B.); Structural Heart and Valve Center, Vanderbilt University Medical Center, Nashville, TN (B.R.L.); Northwestern University Feinberg School of Medicine, Chicago, IL (R.O.B.); Brigham and Women's Hospital, Harvard Medical School, Boston, MA (P.T.O.); and Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Québec, Canada (P.G.)
| | - Jeroen J Bax
- From Clinical Trials Center, Cardiovascular Research Foundation, New York (B.R., D.B., M.B.L., P.G.); Sahlgrenska University Hospital, Gothenburg, Sweden (B.R.); Pulmonary Hypertension and Vascular Biology Research Group, Laval University, Québec, Canada (P.P.); Gagnon Cardiovascular Institute, Morristown Medical Center, NJ (L.D.G., P.G.); Columbia University Medical Center, New York (D.B., M.B.L., P.G.); Leiden University Medical Center, The Netherlands (J.J.B.); Structural Heart and Valve Center, Vanderbilt University Medical Center, Nashville, TN (B.R.L.); Northwestern University Feinberg School of Medicine, Chicago, IL (R.O.B.); Brigham and Women's Hospital, Harvard Medical School, Boston, MA (P.T.O.); and Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Québec, Canada (P.G.)
| | - Brian R Lindman
- From Clinical Trials Center, Cardiovascular Research Foundation, New York (B.R., D.B., M.B.L., P.G.); Sahlgrenska University Hospital, Gothenburg, Sweden (B.R.); Pulmonary Hypertension and Vascular Biology Research Group, Laval University, Québec, Canada (P.P.); Gagnon Cardiovascular Institute, Morristown Medical Center, NJ (L.D.G., P.G.); Columbia University Medical Center, New York (D.B., M.B.L., P.G.); Leiden University Medical Center, The Netherlands (J.J.B.); Structural Heart and Valve Center, Vanderbilt University Medical Center, Nashville, TN (B.R.L.); Northwestern University Feinberg School of Medicine, Chicago, IL (R.O.B.); Brigham and Women's Hospital, Harvard Medical School, Boston, MA (P.T.O.); and Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Québec, Canada (P.G.)
| | - Robert O Bonow
- From Clinical Trials Center, Cardiovascular Research Foundation, New York (B.R., D.B., M.B.L., P.G.); Sahlgrenska University Hospital, Gothenburg, Sweden (B.R.); Pulmonary Hypertension and Vascular Biology Research Group, Laval University, Québec, Canada (P.P.); Gagnon Cardiovascular Institute, Morristown Medical Center, NJ (L.D.G., P.G.); Columbia University Medical Center, New York (D.B., M.B.L., P.G.); Leiden University Medical Center, The Netherlands (J.J.B.); Structural Heart and Valve Center, Vanderbilt University Medical Center, Nashville, TN (B.R.L.); Northwestern University Feinberg School of Medicine, Chicago, IL (R.O.B.); Brigham and Women's Hospital, Harvard Medical School, Boston, MA (P.T.O.); and Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Québec, Canada (P.G.)
| | - Patrick T O'Gara
- From Clinical Trials Center, Cardiovascular Research Foundation, New York (B.R., D.B., M.B.L., P.G.); Sahlgrenska University Hospital, Gothenburg, Sweden (B.R.); Pulmonary Hypertension and Vascular Biology Research Group, Laval University, Québec, Canada (P.P.); Gagnon Cardiovascular Institute, Morristown Medical Center, NJ (L.D.G., P.G.); Columbia University Medical Center, New York (D.B., M.B.L., P.G.); Leiden University Medical Center, The Netherlands (J.J.B.); Structural Heart and Valve Center, Vanderbilt University Medical Center, Nashville, TN (B.R.L.); Northwestern University Feinberg School of Medicine, Chicago, IL (R.O.B.); Brigham and Women's Hospital, Harvard Medical School, Boston, MA (P.T.O.); and Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Québec, Canada (P.G.)
| | - Martin B Leon
- From Clinical Trials Center, Cardiovascular Research Foundation, New York (B.R., D.B., M.B.L., P.G.); Sahlgrenska University Hospital, Gothenburg, Sweden (B.R.); Pulmonary Hypertension and Vascular Biology Research Group, Laval University, Québec, Canada (P.P.); Gagnon Cardiovascular Institute, Morristown Medical Center, NJ (L.D.G., P.G.); Columbia University Medical Center, New York (D.B., M.B.L., P.G.); Leiden University Medical Center, The Netherlands (J.J.B.); Structural Heart and Valve Center, Vanderbilt University Medical Center, Nashville, TN (B.R.L.); Northwestern University Feinberg School of Medicine, Chicago, IL (R.O.B.); Brigham and Women's Hospital, Harvard Medical School, Boston, MA (P.T.O.); and Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Québec, Canada (P.G.)
| | - Philippe Généreux
- From Clinical Trials Center, Cardiovascular Research Foundation, New York (B.R., D.B., M.B.L., P.G.); Sahlgrenska University Hospital, Gothenburg, Sweden (B.R.); Pulmonary Hypertension and Vascular Biology Research Group, Laval University, Québec, Canada (P.P.); Gagnon Cardiovascular Institute, Morristown Medical Center, NJ (L.D.G., P.G.); Columbia University Medical Center, New York (D.B., M.B.L., P.G.); Leiden University Medical Center, The Netherlands (J.J.B.); Structural Heart and Valve Center, Vanderbilt University Medical Center, Nashville, TN (B.R.L.); Northwestern University Feinberg School of Medicine, Chicago, IL (R.O.B.); Brigham and Women's Hospital, Harvard Medical School, Boston, MA (P.T.O.); and Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Québec, Canada (P.G.).
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3
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Redfors B, Furer A, Lindman BR, Burkhoff D, Marquis-Gravel G, Francese DP, Ben-Yehuda O, Pibarot P, Gillam LD, Leon MB, Généreux P. Biomarkers in Aortic Stenosis: A Systematic Review. STRUCTURAL HEART-THE JOURNAL OF THE HEART TEAM 2017. [DOI: 10.1080/24748706.2017.1329959] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Björn Redfors
- Cardiovascular Research Foundation, New York, NY, USA
- Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Ariel Furer
- Cardiovascular Research Foundation, New York, NY, USA
| | | | - Daniel Burkhoff
- Cardiovascular Research Foundation, New York, NY, USA
- NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA
| | | | | | - Ori Ben-Yehuda
- Cardiovascular Research Foundation, New York, NY, USA
- NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA
| | - Philippe Pibarot
- Pulmonary Hypertension and Vascular Biology Research Group, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Québec, Québec, Canada
| | - Linda D. Gillam
- Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, NJ, USA
| | - Martin B. Leon
- Cardiovascular Research Foundation, New York, NY, USA
- NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA
| | - Philippe Généreux
- Cardiovascular Research Foundation, New York, NY, USA
- Hôpital du Sacré-Coeur de Montréal, Montréal, Québec, Canada
- Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, NJ, USA
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4
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Généreux P, Stone GW, O'Gara PT, Marquis-Gravel G, Redfors B, Giustino G, Pibarot P, Bax JJ, Bonow RO, Leon MB. Natural History, Diagnostic Approaches, and Therapeutic Strategies for Patients With Asymptomatic Severe Aortic Stenosis. J Am Coll Cardiol 2016; 67:2263-2288. [PMID: 27049682 DOI: 10.1016/j.jacc.2016.02.057] [Citation(s) in RCA: 172] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 02/03/2016] [Indexed: 01/06/2023]
Abstract
Aortic stenosis (AS) is one of the most common valvular diseases encountered in clinical practice. Current guidelines recommend aortic valve replacement (AVR) when the aortic valve is severely stenotic and the patient is symptomatic; however, a substantial proportion of patients with severe AS are asymptomatic at the time of first diagnosis. Although specific morphological valve features, exercise testing, stress imaging, and biomarkers can help to identify patients with asymptomatic severe AS who may benefit from early AVR, the optimal management of these patients remains uncertain and controversial. The current report presents a comprehensive review of the natural history and the diagnostic evaluation of asymptomatic patients with severe AS, and is followed by a meta-analysis from reported studies comparing an early AVR strategy to active surveillance, with an emphasis on the level of evidence substantiating the current guideline recommendations. Finally, perspectives on directions for future investigation are discussed.
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Affiliation(s)
- Philippe Généreux
- Columbia University Medical Center, New York, New York; Cardiovascular Research Foundation, New York, New York; Hôpital du Sacré-Coeur de Montréal, Montréal, Canada.
| | - Gregg W Stone
- Columbia University Medical Center, New York, New York; Cardiovascular Research Foundation, New York, New York
| | - Patrick T O'Gara
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Björn Redfors
- Cardiovascular Research Foundation, New York, New York; Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | - Philippe Pibarot
- Pulmonary Hypertension and Vascular Biology Research Group, Laval University, Québec, Canada
| | - Jeroen J Bax
- Leiden University Medical Center, Leiden, the Netherlands
| | - Robert O Bonow
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Martin B Leon
- Columbia University Medical Center, New York, New York; Cardiovascular Research Foundation, New York, New York
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