ESC 2019 | How Benign Is Moderate Aortic Stenosis?

Data from a great Australian registry of nearly 250,000 people with a 5-year follow-up, presented at the European Society of Cardiology (ESC) Congress 2019 in Paris and simultaneously published in J Am Coll Cardiol, suggest that mortality due to severe aortic stenosis is similar to that due to moderate aortic stenosis. These data warn us about the dangers of moderate stenosis, which is not as benign as we thought.

The registry showed that 5-year mortality rates were 67% in patients with severe aortic stenosis (both high-gradient and low-gradient) and 56% in those with moderate aortic stenosis. Such mortality is substantially greater than that shown in previous observational studies.

These results should make us rethink how we manage patients with mean aortic valve gradient of 20 mmHg and peak velocity of 3 m/s. However, among patients with moderate aortic stenosis, there surely are subgroups where the disease may progress more rapidly than in others. Such data are still unclear, and we should be cautious before changing our clinical practice.

As regards this registry, absence of aortic stenosis was considered as mean gradient <10 mmHg and peak velocity <2 m/s; mild, as mean gradient 10-19.9 mmHg and peak velocity 2-2.9 m/s; moderate, as mean gradient 20-39.9 mmHg, peak velocity 3-3.9 m/s, and an area >1 cm2; severe high-gradient aortic stenosis, as mean gradient >40 mmHg or peak velocity >4.0 m/s with an area ≤1 cm2 or severe low-gradient, as an area ≤1 cm2.

Read also: ESC 2019 | CLARIFY: Symptoms Predict Risk Only in Patients with Prior MI.

The analysis showed that, as peak velocity increases, mean gradient increases, and valve area decreases, mortality increases; however, there are no significant differences in the cutoff for moderate and severe aortic stenosis.

Many patients with moderate aortic stenosis may die from comorbid disease that would not necessarily require more aggressive management of valve disease. Another explanation for the lack of difference in mortality could be that patients identified as having moderate aortic stenosis at baseline progressed rapidly to severe aortic stenosis (and a consequently high risk of death) during follow-up.

Current guidelines from the American College of Cardiology (ACC)/American Heart Association (AHA) recommend close follow-up with annual echocardiography, so as to monitor the eventual progression of moderate aortic stenosis. However, that may not be enough for some patients.

Original title: Poor long-term survival in patients with moderate aortic stenosis.

Reference: Strange G et al. J Am Coll Cardiol. 2019; Epub ahead of print.

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