Sudden Death in Patients With Severe Aortic Stenosis: Observations From the CURRENT AS Registry

Abstract

BackgroundThe annual incidence of sudden death has been reported to be low (<1%/year) in asymptomatic patients with severe aortic stenosis (AS), and there is a paucity of data on the risk factors of sudden death in patients with severe AS.Methods and ResultsWe evaluated the incidence and risk factors of sudden death during the median follow‐up period of 1334 days in the Contemporary Outcomes After Surgery and Medical Treatment in Patients With Severe Aortic Stenosis (CURRENT AS) registry enrolling 3815 consecutive patients with severe AS between 2003 and 2011. The mean age was 78 years, and the prevalences of male sex and prior myocardial infarction were 38% and 8%, respectively. Sudden death occurred in 175 patients without aortic valve replacement. The cumulative 5‐year incidences of sudden death, censored at aortic valve replacement, which accounted for the competing risk, were 9.2% in symptomatic patients and 7.2% (1.4%/year) in asymptomatic patients (P<0.001). Among 82 asymptomatic patients experiencing sudden death, 54 patients (66%) died abruptly without any preceding symptoms, and 35 (65%) of these sudden deaths occurred within 3 months of the last clinical follow‐up visit. Independent risk factors for sudden death were hemodialysis (hazard ratio [HR] 3.63; 95% confidence interval [CI] 2.42‐5.43), prior myocardial infarction (HR 2.11; 95% CI 1.28‐3.50), body mass index <22 (HR 1.51; 95% CI 1.03‐2.21), peak aortic jet velocity ≥5 m/s (HR 1.76; 95% CI 1.12‐2.78), and left ventricular ejection fraction <60% (HR 1.52; 95% CI 1.08‐2.14).ConclusionsThe incidence of sudden death in asymptomatic patients with severe AS might be higher than that reported in previous reports. Several baseline clinical and echocardiographic characteristics were associated with increased risk of sudden death.Clinical Trial Registration URL: http://www.umin.ac.jp/ctr/index.htm. Unique identifier: UMIN000012140.

Sudden cardiac death: an update

“…Valvular heart disease can cause SCD through both mechanical and arrhythmogenic mechanisms. Asymptomatic severe aortic stenosis has traditionally been thought to pose low risk of SCD at around 1% per year but newer data suggest that this figure is likely closer to 5–7% . There has long been an association between mitral valve prolapse and SCD due to ventricular arrhythmias with an estimated risk of 0.2–1.9% but the incidence is poorly defined …”

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

“…Baseline characteristics of the study patients were previously reported in detail 8 10 11. Briefly, among the 3815 patients with severe AS enrolled in this registry, the mean age was 77.8 years, which was much older than in the previous reports,12–15 and 1443 patients (38%) were men.…”

“…Third, SAVR after symptom development might be carrying higher operative risk than SAVR during the asymptomatic phase 33. Fourth, the annual rate of sudden death during the asymptomatic phase might be higher (1.4%/year) than the rate (<1.0%/year) reported previously 10 13–15. Finally, in the CURRENT AS registry, 41% of patients managed conservatively required AVR within a median follow-up of 2 years, suggesting that one does not gain much by waiting (figure 4).…”

“…In the CURRENT AS registry, symptomatic patients at baseline were much older and more often had atrial fibrillation or flutter, coronary artery disease or anaemia than asymptomatic patients 10. Surgical risk scores such as logistic EuroSCORE, EuroSCORE II and STS score were significantly higher in symptomatic patients than in asymptomatic patients.…”

Transcatheter management of severe aortic stenosis during the COVID-19 pandemic

“…Should symptoms develop, clinical deterioration may progress rapidly, and the risk of sudden death can escalate if AS is managed conservatively (4% at 1 month, 12% at 6 months). 20 In a recent study of AS patients with a high probability of LV decompensation, more than 50% were either dead or hospitalised with cardiac failure within 2 years. 21 Timing of intervention is also crucial, as perioperative morbidity is markedly increased if advanced left ventricular systolic dysfunction occurs due to a delay in intervention.…”