Advance Directives of Patients With High-Risk or Inoperable Aortic Stenosis | Valvular Heart Disease | JAMA Internal Medicine | JAMA Network
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Table 1.  Demographic and Clinical Characteristics of Patientsa
Demographic and Clinical Characteristics of Patientsa
Table 2.  Advance Directive Completion and Content Data
Advance Directive Completion and Content Data
Research Letter
September 2014

Advance Directives of Patients With High-Risk or Inoperable Aortic Stenosis

Author Affiliations
  • 1Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
  • 2Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
  • 3Department of Radiology, Mayo Clinic, Rochester, Minnesota
  • 4Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota
JAMA Intern Med. 2014;174(9):1516-1518. doi:10.1001/jamainternmed.2014.3453

Severe, symptomatic aortic stenosis (AS) is associated with high morbidity and mortality rates, which can be reduced with surgical aortic valve replacement and transcatheter aortic valve replacement (TAVR).1,2 However, patients who have these procedures may experience procedure-related morbidity (eg, stroke, vascular complications, and arrhythmia) and death.2 Thus, regardless of treatment approach, patients with severe AS should engage in advance care planning, which includes documenting their end-of-life values, goals, and preferences in an advance directive (AD). Advance directives are written instructions for future health care in the event that a patient loses decision-making capacity. In this study, we determined the prevalence and contents of ADs of patients with symptomatic severe AS and high surgical risk or inoperable status.


This study was approved by the Mayo Clinic Institutional Review Board. Adult patients with severe AS evaluated at Mayo Clinic in Rochester, Minnesota, from January 1, 2008, through December 31, 2012, who met the criteria for TAVR were identified in the Mayo Clinic TAVR database. Severe AS was defined using the American Society of Echocardiography guidelines and criteria to qualify for TAVR (aortic valve area of <1 cm2 or <0.5 cm2/m2 and an aortic valve mean gradient >40 mm Hg or aortic valve peak velocity >4 m/s). For aortic valve replacement, high-risk surgical patients were defined as having a calculated Society of Thoracic Surgeons risk of mortality of 8% or more or an estimated risk of surgical mortality of 10% or more. Patients with inoperable status were defined by 2 cardiac surgeons (R.M.S. and K.L.G.) as having an estimated risk of morbidity or mortality of 50% or more with isolated aortic valve replacement or, less commonly, having a technical reason precluding an operation.3,4

All patients at Mayo Clinic are asked whether they have an AD. If they do, they are asked for a copy, which is scanned into the electronic medical record. If not, they are offered the opportunity to complete an AD.

Demographic and clinical data were abstracted from each patient’s medical record; no patients were contacted. For patients who had ADs, data were abstracted from the ADs. Descriptive and comparative statistics (the χ2 test or the Fisher exact test, as appropriate, for categorical variables or the 2-sample t test for continuous variables) were used. P< .05 was considered statistically significant.


Overall, 251 patients (mean age, 81.0 years; 56% male) met the inclusion criteria (Table 1). Of these, 117 (47%) had ADs; 48 of the 117 (41%) were female and 69 (59%) were male. There were no significant differences in the demographic and clinical characteristics between patients with and without ADs. Data on the completion and contents of the ADs are shown in Table 2. Some ADs addressed commonly used life-prolonging treatments. However, most ADs (89%) named a surrogate decision maker.


This study had several important findings. Fewer than half the patients had ADs; of those who did, no more than a third addressed life-prolonging treatments. These findings are relevant given the high mortality rate among patients with symptomatic severe AS. Such patients should document their health care–related values, goals, and preferences in ADs (eg, preferences regarding invasive life-prolonging treatments, comfort measures, or hospice care).

Fortunately, most patients who had ADs listed surrogate decision makers in their ADs. Presumably, surrogates (usually spouses, children, or friends) are familiar with patients’ values, goals, and preferences. A patient can never anticipate all future health care scenarios. Hence, patient autonomy can be maximized by identifying an appropriate surrogate.

Future research should focus on identifying means of eliminating barriers to AD completion and increasing AD completion rates among patients with heart disease, such as those in this study.

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Article Information

Corresponding Author: Paul S. Mueller, MD, MPH, Division of General Internal Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905 (

Published Online: August 4, 2014. doi:10.1001/jamainternmed.2014.3453.

Author Contributions: Drs Nkomo and Mueller had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Rihal, Mueller.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Nkomo, Suri, Pislaru, Mueller.

Critical revision of the manuscript for important intellectual content: Suri, Greason, Mathew, Rihal, Mueller.

Statistical analysis: Nkomo, Mueller.

Obtained funding: Nkomo, Mueller.

Administrative, technical, or material support: Suri, Pislaru, Greason, Rihal, Mueller.

Study supervision: Rihal, Mueller.

Conflict of Interest Disclosures: Dr Mueller reports being a member of the Boston Scientific Patient Safety Advisory Board and an associate editor of New England Journal of Medicine’s Journal Watch General Medicine. No other disclosures were reported.

Funding/Support: Funding for data collection was provided by the Department of Internal Medicine,Mayo Clinic, Rochester, Minnesota; funding for data management, analysis, and interpretation as well as preparation, review, and approval of the manuscript was provided by the Divisions of Cardiovascular Diseases and General Internal Medicine, Mayo Clinic, Rochester.

Role of the Sponsor: Mayo Clinic, Rochester, had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: David R. Holmes, MD, Division of Cardiovascular Diseases, Mayo Clinic, Rochester, helped with review and critical revision of the manuscript for important intellectual content, and Christopher G. Scott, MS, Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, helped with statistical analysis.

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