The progression of aortic stenosis has been extensively studied and is well-known. As observed, in its advanced stages, this condition entails high morbidity and a marked decrease in survival. Both North American and European guidelines recommend treatment when faced with severe valve disease. However, true severity can be difficult to determine due to discordant data, such as peak velocity not matching the valve area.

Underestimation of severity leads to undertreatment, worsening the prognosis. Based on this premise, the group led by Généreux et al. aimed to assess mortality across the spectrum of untreated aortic stenosis in a contemporary cohort.

The studied population was compiled from 1,669,536 echocardiograms corresponding to a database of 1,085,850 patients. The presence of aortic stenosis was classified by severity as none, mild, mild to moderate, moderate to severe, and severe. Events were evaluated at 4 years, with all-cause mortality related to untreated aortic stenosis as the study’s primary endpoint. The secondary endpoint was time until treatment with aortic valve replacement (AVR).

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A total of 595,120 patients met the eligibility criteria, with a mean time from diagnosis to treatment, last follow-up, or mortality of 421 days. Of the total, 11.9% had some degree of aortic stenosis, while 81.1% showed no evidence of this condition. Among patients with aortic stenosis, 86.6% were classified as mild, moderate, or severe, and 13.4% as mild to moderate or moderate to severe.

Overall, patients in more severe stages experienced higher morbidity, were older, and had a greater likelihood of concomitant valve pathologies, such as tricuspid or mitral regurgitation. There was some degree of discordance in severity in 22.8% of all moderate cases and 59.8% of all moderate to severe cases.

The estimated untreated all-cause mortality at 4 years, associated with a diagnosis of aortic stenosis from none to mild, mild to moderate, moderate, moderate to severe, or severe, was 13.5% (95% confidence interval [CI]: 13.3%-13.7%), 25.0% (95% CI: 23.8%-26.1%), 29.7% (95% CI: 26.8%-32.5%), 33.5% (95% CI: 31.0%-35.8%), 45.7% (95% CI: 37.4%-52.8%), and 44.9% (95% CI: 39.9%-49.6%), respectively. The rate for AVR treatment was 1% in mild cases and 60.7% in severe cases.

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An analysis using the hazard model demonstrated a trend of increased mortality with each increment in aortic stenosis severity. After adjustment, all degrees of aortic stenosis severity were associated with a higher risk of untreated mortality.

Conclusions

Diagnoses of intermediate severity (mild to moderate or moderate to severe) are common in daily practice according to this analyzed cohort and are associated with mortality similar to their next more severe grade of aortic stenosis. Significant undertreatment of severe aortic stenosis is notable, with AVR conducted in only 60% of patients up to 4 years after the initial diagnosis. The risk of mortality with aortic stenosis gradually increased across the spectrum of disease severity, emphasizing the importance of rigorous monitoring and early intervention.

Dr. Omar Tupayachi.
Member of the Editorial Board of SOLACI.org.

Original Title: The Mortality Burden of Untreated Aortic Stenosis.

Reference: Généreux P, Sharma RP, Cubeddu RJ, Aaron L, Abdelfattah OM, Koulogiannis KP, Marcoff L, Naguib M, Kapadia SR, Makkar RR, Thourani VH, van Boxtel BS, Cohen DJ, Dobbles M, Barnhart GR, Kwon M, Pibarot P, Leon MB, Gillam LD. The Mortality Burden of Untreated Aortic Stenosis. J Am Coll Cardiol. 2023 Oct 20:S0735-1097(23)07504-6. doi: 10.1016/j.jacc.2023.09.796. Epub ahead of print. PMID: 37877909.

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