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Original Investigation
September 29, 2021

Association of Mortality With Aortic Stenosis Severity in Outpatients: Results From the VALVENOR Study

Author Affiliations
  • 1University Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1011- EGID, Lille, France
  • 2University of Liège Hospital, GIGA Cardiovascular Sciences, Department of Cardiology, Heart Valve Clinic, CHU Sart Tilman, Liège, Belgium
  • 3Gruppo Villa Maria Care and Research, Maria Cecilia Hospital, Cotignola, Anthea Hospital, Bari, Italy
  • 4University Lille, Inserm, CHU Lille, Institut Pasteur, U1167, Lille, France
JAMA Cardiol. Published online September 29, 2021. doi:10.1001/jamacardio.2021.3718
Key Points

Question  What is the outcome of outpatients with aortic stenosis (AS) in the current era?

Findings  In this cohort study including 2703 patients followed up by 117 cardiologists for a median of 2.1 years, patients with moderate AS had a slightly higher risk of cardiovascular death than patients with mild AS, but this risk was much lower than that observed in severe AS. Moreover, in asymptomatic patients, moderate and mild AS was associated with similar cardiovascular mortality.

Meaning  Asymptomatic patients with moderate AS undergoing standard symptomatic and echocardiographic follow-up may not be exposed to an increased risk of mortality.

Abstract

Importance  Modern data regarding incidence and modes of death of patients with aortic stenosis (AS) are restricted to tertiary centers or studies of aortic valve replacement (AVR).

Objective  To provide new insights into the natural history of outpatients with native AS based on a large regionwide population study with inclusion by all cardiologists regardless of their mode of practice.

Design, Setting, and Participants  Between May 2016 and December 2017, consecutive outpatients with mild (peak aortic velocity, 2.5-2.9 m/s), moderate (peak aortic velocity, 3-3.9 m/s), and severe (peak aortic velocity, ≥4 m/s) native AS graded by echocardiography were included by 117 cardiologists from the Nord-Pas-de-Calais region in France. Analysis took place between August and November 2020.

Main Outcomes and Measures  Natural history, need for AVR, and survival of patients with AS were followed up. Indications for AVR were based on current guideline recommendations.

Results  Among 2703 patients (mean [SD] age, 76.0 [10.8] years; 1260 [46.6%] women), 233 (8.6%) were recruited in a university public hospital, 757 (28%) in nonuniversity public hospitals, and 1713 (63.4%) by cardiologists working in private practice. A total of 1154 patients (42.7%) had mild, 1122 (41.5%) had moderate, and 427 (15.8%) had severe AS. During a median (interquartile range) of 2.1 (1.4-2.7) years, 634 patients underwent AVR and 448 died prior to AVR. Most deaths were cardiovascular (200 [44.7%]), mainly associated with congestive heart failure (101 [22.6%]) or sudden death (60 [13.4%]). Deaths were noncardiovascular in 186 patients (41.5%) and from unknown causes in 62 patients (13.8%). Compared with patients with mild AS, there was increased cardiovascular mortality in those with moderate (hazard ratio, 1.47 [95% CI, 1.07-2.02]) and severe (hazard ratio, 3.66 [95% CI, 2.52-5.31]) AS. The differences remained significant when adjusted for baseline characteristics or in time-dependent analyses considering AS progression. In asymptomatic patients, moderate and mild AS were associated with similar cardiovascular mortality (hazard ratio, 0.99 [95% CI, 0.44-2.21]).

Conclusions and Relevance  While patients in this study with moderate AS had a slightly higher risk of cardiovascular death than patients with mild AS, this risk was much lower than that observed in patients with severe AS. Moreover, in asymptomatic patients, moderate and mild AS were associated with similar cardiovascular mortality.

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