Reasons for Choosing Conservative Management in Symptomatic Patients With Severe Aortic Stenosis　― Observations From the CURRENT AS Registry ―

Ishii, Mitsuru; Taniguchi, Tomohiko; Morimoto, Takeshi; Ogawa, Hisashi; Masunaga, Nobutoyo; Abe, Mitsuru; Yoshikawa, Yusuke; Shiomi, Hiroki; Ando, Kenji; Kanamori, Norio; Murata, Katsuyuki; Kitai, Takeshi; Kawase, Yoshiaki; Izumi, Chisato; Miyake, Makoto; Mitsuoka, Hirokazu; Kato, Masashi; Hirano, Yutaka; Matsuda, Shintaro; Nagao, Keisuke; Inada, Tsukasa; Mikami, Hiroshi; Takeuchi, Yasuyo; Yamane, Keiichiro; Toyofuku, Mamoru; Minamino‐Muta, Eri; Kato, Takao; Inoko, Moriaki; Ikeda, Tomoyuki; Komasa, Akihiro; Ishii, Katsuhisa; Hotta, Kozo; Higashitani, Nobuya; Kato, Yoshihiro; Inuzuka, Yasutaka; Jinnai, Toshikazu; Morikami, Yasuhiro; Akao, Masaharu; Minatoya, Kenji; Kimura, Takeshi

doi:10.1253/circj.cj-19-0247

Cited by 9 publications

(6 citation statements)

References 27 publications

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“…Contemporary studies have reported a 12-month mortality rate postdiagnosis of 30%–60% in patients who did not undergo valve replacement due to potential medical futility, and 17%–45% in those not undergoing AVR for other reasons (most commonly due to patient refusal). 24 25 Further data from Spain cited frailty as the principal reason for opting against an invasive strategy in 44% of conservatively managed cases, with 42% mortality at 12 months in this group. 26 Defining a CFS score which would denote medical futility would be an important part of this assessment—outcome data relating to the CFS as a continuous variable was only available from two of our included studies, however, a score of ≥7 was associated with 33% and 45% 12-month mortality post-intervention.…”

Section: Discussionmentioning

confidence: 95%

Clinical Frailty Scale as a predictor of adverse outcomes following aortic valve replacement: a systematic review and meta-analysis

et al. 2023

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ObjectivesAssessment of frailty prior to aortic valve intervention is recommended in European and North American valvular heart disease guidelines. However, there is a lack of consensus on how it is best measured. The Clinical Frailty Scale (CFS) is a well-validated measure of frailty that is relatively quick to calculate. This meta-analysis sought to examine whether the CFS predicts mortality and morbidity following either transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement (SAVR).MethodsNine electronic databases were searched systematically for data on clinical outcomes post-TAVI/SAVR, where patients had undergone preoperative frailty assessment using the CFS. The primary endpoint was 12-month mortality. TAVI and SAVR data were assessed and reported separately. For each individual study, the incidence of adverse outcomes was extracted according to a CFS score of 5–9 (ie, frail) versus 1–4 (ie, non-frail), with meta-analysis performed using a random effects model.ResultsOf 2612 records screened, nine were included in the review (five TAVI, three SAVR and one which included both interventions). Among 4923 TAVI patients, meta-analysis showed 12-month mortality rates of 19.1% for the frail cohort versus 9.8% for the non-frail cohort (RR 2.53 (1.63 to 3.95), p<0.001, I2=83%). For the smaller cohort of SAVR patients (n=454), mortality rates were 20.3% versus 3.9% for the frail and non-frail cohorts, respectively (RR 5.08 (2.31 to 11.15), p<0.001, I2=5%).ConclusionsFrailty, as determined by the CFS, was associated with an increased mortality risk in the 12 months following either TAVI or SAVR. These data would support its use in the preoperative assessment of elderly patients undergoing aortic valve interventions.

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Section: Discussionmentioning

confidence: 95%

Clinical Frailty Scale as a predictor of adverse outcomes following aortic valve replacement: a systematic review and meta-analysis

et al. 2023

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“…Running Title: SEX DIFFERENCES IN SEVERE AS 10 One of the most significant reasons for not pursuing SAVR within our cohort was patient preference, which is also identified within the literature amongst female patients. [19][20][21][22] Despite being a large study, limitations of our study include that it was conducted within a single institution with a single electronic medical record. This project therefore does not account for hospitalizations, diagnoses, and events obtained outside of the Vancouver Coastal Health jurisdiction and assumed that patients of our study only obtained care within this health authority.…”

Section: Discussionmentioning

confidence: 99%

Sex-differences in Newly Diagnosed Severe Aortic Stenosis in British Columbia (B.C.) between 2012 - 2022

Roshan,

Yim,

Lakhani

et al. 2024

Preprint

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BackgroundDespite its high prevalence, little is known about the effect of sex on the management and outcomes of aortic stenosis (AS). We sought to characterize the effect of sex on the clinical evaluation for and provision of aortic valve replacement (AVR), including surgical (SAVR) and transcatheter aortic valve replacement (TAVR), and subsequent morbidity and mortality outcomes.MethodsA comprehensive chart review was conducted on all patients with a first diagnosis of severe aortic stenosis (AS) at Vancouver General and University of British Columbia Hospitals from 2012 to 2022. Exact chi-square and Kruskal-Wallis tests were used to evaluate variables of interest.ResultsA total of 1794 studies met inclusion criteria, comprising 782 females (44%) and 1012 males (56%). Females were significantly older than males at the time of first diagnosis (79 versus 75 years, p<0.001). Females were significantly less likely to be evaluated by the TAVR clinic, cardiac surgeon, or to receive aortic valve intervention (p-value≤0.001).Females were significantly more likely to be rejected for TAVR due to older age (OR 0.23 (0.07, 0.59)), comorbid conditions (OR 0.68 (0.47, 0.97)), and frailty (OR 0.23 (0.07, 0.59)). Females were significantly more likely to be rejected for SAVR on the basis of frailty (OR 0.66 (0.46, 0.94)). Females also had significantly higher rates of 1-year mortality, hospitalization, and heart failure hospitalization compared to males (p-values < 0.05).ConclusionOur data suggest significant sex-based discrepancies in the management of AS. Females with severe AS are diagnosed later in life and are less likely to be evaluated for valve intervention. They are less likely to receive intervention due to older age, frailty, and multimorbid conditions. Further research is warranted for more effective identification and follow up of aortic stenosis as well as timely referral for AVR, where appropriate, especially of females.

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“…In the CURRENT AS registry, symptomatic patients who refused SAVR had less comorbidities and lower STS score but had similarly dismal outcomes as compared with patients who were not referred to AVR due to unacceptably high surgical risk based on the physician judgement. This observation highlighted the profound risk of patient rejection for AVR, as well as the risk of delaying AVR, which the patients and the family members should be adequately informed of 23…”

Section: Under-referral/underuse Of Savr In Symptomatic Patients Withmentioning

confidence: 95%

Contemporary issues in severe aortic stenosis: review of current and future strategies from the Contemporary Outcomes after Surgery and Medical Treatment in Patients with Severe Aortic Stenosis registry

Taniguchi

Morimoto

Takeji

et al. 2020

Heart

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Contemporary Outcomes after Surgery and Medical Treatment in Patients with Severe Aortic Stenosis (CURRENT AS) registry was a large Japanese multicentre retrospective registry of consecutive patients with severe aortic stenosis (AS) before introduction of transcatheter aortic valve implantation. We sought to overview the data from the CURRENT AS registry to discuss the three major contemporary issues related to clinical practice in patients with severe AS: (1) under-referral/underuse of surgical aortic valve replacement (SAVR) in symptomatic patients with severe AS, (2) management of asymptomatic patients with severe AS and (3) management of patients with low-gradient severe aortic stenosis (LG-AS). First, despite the dismal prognosis of symptomatic patients with severe AS, SAVR, including those performed during follow-up, was reported to be underused. In the CURRENT AS registry, overall 53% of symptomatic patients underwent aortic valve replacement (AVR) during follow-up. Second, we reported that compared with conservative strategy, initial AVR strategy was associated with lower risk of all-cause death and heart failure hospitalisation in asymptomatic patients with severe AS. Although current recommendations for AVR are mainly dependent on the patient symptoms, some patients may not complain of any symptom because of their sedentary lifestyle. We also reported several important objective factors associated with worse clinical outcomes in asymptomatic patients with severe AS for risk stratification. Finally, initial AVR strategy was associated with better long-term clinical outcomes than conservative strategy in both patients with high-gradient AS and patients with LG-AS. The favourable effect of initial AVR strategy was also seen in patients with LG-AS with left ventricular ejection fraction of ≥50%.

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Reasons for Choosing Conservative Management in Symptomatic Patients With Severe Aortic Stenosis　― Observations From the CURRENT AS Registry ―

Cited by 9 publications

References 27 publications

Clinical Frailty Scale as a predictor of adverse outcomes following aortic valve replacement: a systematic review and meta-analysis

Clinical Frailty Scale as a predictor of adverse outcomes following aortic valve replacement: a systematic review and meta-analysis

Sex-differences in Newly Diagnosed Severe Aortic Stenosis in British Columbia (B.C.) between 2012 - 2022

Contemporary issues in severe aortic stenosis: review of current and future strategies from the Contemporary Outcomes after Surgery and Medical Treatment in Patients with Severe Aortic Stenosis registry

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Reasons for Choosing Conservative Management in Symptomatic Patients With Severe Aortic Stenosis ― Observations From the CURRENT AS Registry ―

Cited by 9 publications

References 27 publications

Clinical Frailty Scale as a predictor of adverse outcomes following aortic valve replacement: a systematic review and meta-analysis

Clinical Frailty Scale as a predictor of adverse outcomes following aortic valve replacement: a systematic review and meta-analysis

Sex-differences in Newly Diagnosed Severe Aortic Stenosis in British Columbia (B.C.) between 2012 - 2022

Contemporary issues in severe aortic stenosis: review of current and future strategies from the Contemporary Outcomes after Surgery and Medical Treatment in Patients with Severe Aortic Stenosis registry

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Reasons for Choosing Conservative Management in Symptomatic Patients With Severe Aortic Stenosis　― Observations From the CURRENT AS Registry ―