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 PARTICIPANTSBetween 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, Ն4 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 RELEVANCEWhile 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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Background: As the population ages, the prevalence of atrial fibrillation (AF) is increasing. This leads to significant healthcare resource use – mainly the cost of hospitalization. Using guidelines, we built the Ambulatory Care Score for Atrial Fibrillation (ACSAF) for application in emergency departments (EDs) that lack a cardiologist. The primary objective of the present study was to validate the ACSAF for the triage of new-onset AF (NOAF) by comparison with the cardiologist’s opinion.Methods: This single-centre, prospective, observational, comparative study was performed at a general hospital between November 2018 and October 2019. All adult patients with NOAF were included. Patients with a systolic blood pressure <80 mmHg or a heart rate >180 bpm were excluded. The ACSAF was calculated by an ED physician in blind to the cardiologist’s opinion. The primary outcome was the mean difference in the ACSAF between ambulatory care group and the hospital care group. A receiver operating characteristic (ROC) curve was plotted to determine the optimal cut-off for the ACSAF. Results: 81 patients with NOAF (42 men (51.9%); mean age: 69 ±16 years old) were included in the study. The mean ACSAF was higher in the hospital care group (2.16 ±1.05) than in the ambulatory care group (1.03 ±0.97; p<0.0001). The optimal ACSAF cut-off was 2, giving a sensitivity [95% confidence interval] of 71.4%[57.1-83.7] and a specificity of 81.2%[68.8-93.8]. Discussion & Conclusion: The ACSAF enables ED physicians to decide on the triage of NOAF in the absence of a cardiologist’s opinion.Trial registration: ANSM (French Drug Administration) : ID RCB 2018-A01800-55 French National Data Protection Commission (Commission nationale de l'informatique et des libertés (Paris, France); reference: MRC-003 2197970, June 2nd, 2018)

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