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Ms Patricia Pellikka
Prof. Thierry Le Tourneau
Prof. Joseph Malouf
Aortic stenosis (AS) predominantly affects the elderly population and is increasingly recognised as a heterogeneous syndrome with variable and non-specific symptom response. Patients may have “discordant” echocardiographic markers of severity, so clear categorisation of their disease state is challenging. Furthermore, co-morbidities are frequent and further confound the clinical picture.
In an attempt to reduce selection bias associated with studies from specialist centres, this community cohort study followed patients with AS diagnosed between 1988 and 1997 in Olmsted County, US. Primary and secondary end points were survival after diagnosis under medical management and development of heart failure, respectively. 360 patients (mean age 74±14 years, 44% male) with at least mild AS and mean ejection fraction 60±13% were divided according to their aortic valve area (AVA) derived by continuity equation, into mild (>1.5cm2), moderate (1–1.5cm2) and severe stenosis (<1cm2), irrespective of trans-valve gradient. Over a follow up period of 7.5±4.2 years the authors assessed factors related to survival. Impressively, follow up data were available in all but one patient. An AVA <1cm2 was associated with reduced 5- and 8-year survival in comparison with an AVA 1.0-1.5cm2 (40±8 vs. 73±3%, 18±6 vs. 54±4%) and increased frequency of the development of heart failure, and was the only independent predictor of survival (p <0.01). The need for aortic valve replacement (AVR) over follow up varied as follows: AVA<1cm2 45%; AVA 1-1.5cm2 33%; AVA>1.5cm2 34%. Importantly, symptoms were also present in two thirds of those who did not undergo surgery for a variety of reasons: AS not judged severe (56%); too old (24%); equivocal symptoms (43%); patient declined (20%); physician choice (20%).
The study confirms that severe AS is under-recognised and under-treated but has important limitations. Defining AS using the continuity equation is prone to error and the equipment used today has superior definition to that used at the time of enrolment. However, the data reflect “real world” practice and the substantial difficulties faced in assessing AS in elderly patients. The paper re-emphasises the need to improve symptom assessment and objective parameters of exercise capacity in patients with AS and highlights the poor prognosis of those with an AVA <1cm2.
Journal of Thoracic and Cardiovascular Surgery. December 2012;144:1421-1427.
Presented by : Dr Margaret Loudon, Dr Bernard PrendergastJohn Radcliffe Hospital, Oxford, UK
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