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Factors Affecting Rate of Progression of Aortic Stenosis and Its Impact on Outcomes

Published:October 11, 2022DOI:https://doi.org/10.1016/j.amjcard.2022.09.016
      The rate of aortic stenosis (AS) progression in patients with moderate AS is unclear. This study examined the risk factors of progression from moderate to severe AS and its impact on clinical outcomes. A total of 954 patients with moderate AS (valve area >1.0 and ≤1.5 cm²) and follow-up echocardiograms were included. AS progressed to severe (valve area <1.0 cm
      • Leon MB
      • Smith CR
      • Mack M
      • Miller DC
      • Moses JW
      • Svensson LG
      • Tuzcu EM
      • Webb JG
      • Fontana GP
      • Makkar RR
      • Brown DL
      • Block PC
      • Guyton RA
      • Pichard AD
      • Bavaria JE
      • Herrmann HC
      • Douglas PS
      • Petersen JL
      • Akin JJ
      • Anderson WN
      • Wang D
      • Pocock S
      PARTNER Trial Investigators
      Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery.
      ) in 589 patients (61.7%) over a median follow-up of 2.46 (interquartile range [IQR] 1.29 to 3.91) years. Of those who progressed to severe AS, patients were subdivided into Slow (n = 294, over 3.91 [IQR 3.11 to 5.10] years) versus Fast (n = 295, over 1.29 [IQR 0.85 to 1.85] years) Progressors, according to the median time between the 2 echocardiograms. The correlates of fast AS progression and its impact on cumulative survival and freedom from valve intervention were evaluated. On multivariate analysis, age, thickened left ventricle posterior wall, severe renal impairment, and aortic valve area were significantly associated with fast AS progression. Over a median follow-up of 6.34 (IQR 4.05 to 9.55) years, 228 patients (38.7%) died. Despite similar aortic valve intervention rates, Fast Progressors had worse 5-year survival (61.2% vs 81.9%, log-rank p <0.001) and event-free (valve intervention and all-cause mortality) survival rates (16.2% vs 55.9%, log-rank p <0.001). On multivariable Cox analysis, shorter progression to severe AS (in years) was independently associated with increased risk of all-cause mortality (hazard ratio 1.26, 95% confidence interval 1.16 to 1.37, p <0.001), or combined aortic valve intervention and death (hazard ratio 1.46, 95% confidence interval 1.38 to 1.55, p <0.001). In conclusion, fast progression from moderate to severe AS is associated with worse outcomes.
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      References

        • Leon MB
        • Smith CR
        • Mack M
        • Miller DC
        • Moses JW
        • Svensson LG
        • Tuzcu EM
        • Webb JG
        • Fontana GP
        • Makkar RR
        • Brown DL
        • Block PC
        • Guyton RA
        • Pichard AD
        • Bavaria JE
        • Herrmann HC
        • Douglas PS
        • Petersen JL
        • Akin JJ
        • Anderson WN
        • Wang D
        • Pocock S
        • PARTNER Trial Investigators
        Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery.
        N Engl J Med. 2010; 363: 1597-1607
        • Ross J
        • Braunwald E.
        Aortic stenosis.
        Circulation. 1968; 38: 61-67
        • Kang DH
        • Park SJ
        • Lee SA
        • Lee S
        • Kim DH
        • Kim HK
        • Yun SC
        • Hong GR
        • Song JM
        • Chung CH
        • Song JK
        • Lee JW
        • Park SW.
        Early surgery or conservative care for asymptomatic aortic stenosis.
        N Engl J Med. 2020; 382: 111-119
        • Strange G
        • Stewart S
        • Celermajer D
        • Prior D
        • Scalia GM
        • Marwick T
        • Ilton M
        • Joseph M
        • Codde J
        • Playford D
        National Echocardiography Database of Australia Contributing Sites. Poor long-term survival in patients with moderate aortic stenosis.
        J Am Coll Cardiol. 2019; 74: 1851-1863
        • Iung B
        • Delgado V
        • Rosenhek R
        • Price S
        • Prendergast B
        • Wendler O
        • De Bonis MD
        • Tribouilloy C
        • Evangelista A
        • Bogachev-Prokophiev A
        • Apor A
        • Ince H
        • Laroche C
        • Popescu BA
        • Piérard L
        • Haude M
        • Hindricks G
        • Ruschitzka F
        • Windecker S
        • Bax JJ
        • Maggioni A
        • Vahanian A
        • EORP VHD
        • II Investigators
        Contemporary presentation and management of valvular heart disease: the EURObservational research programme valvular heart disease II survey.
        Circulation. 2019; 140: 1156-1169
        • Iung B
        • Baron G
        • Butchart EG
        • Delahaye F
        • Gohlke-Bärwolf C
        • Levang OW
        • Tornos P
        • Vanoverschelde JL
        • Vermeer F
        • Boersma E
        • Ravaud P
        • Vahanian A.
        A prospective survey of patients with valvular heart disease in Europe: the Euro heart survey on valvular heart disease.
        Eur Heart J. 2003; 24: 1231-1243
        • Nistri S
        • Faggiano P
        • Olivotto I
        • Papesso B
        • Bordonali T
        • Vescovo G
        • Dei Cas L
        • Cecchi F
        • Bonow RO
        Hemodynamic progression and outcome of asymptomatic aortic stenosis in primary care.
        Am J Cardiol. 2012; 109: 718-723
        • Chan KL
        • Teo K
        • Dumesnil JG
        • Ni A
        • Tam J
        • ASTRONOMER Investigators
        Effect of lipid lowering with rosuvastatin on progression of aortic stenosis: results of the aortic stenosis progression observation: measuring effects of rosuvastatin (ASTRONOMER) trial.
        Circulation. 2010; 121: 306-314
        • Rossebø AB
        • Pedersen TR
        • Boman K
        • Brudi P
        • Chambers JB
        • Egstrup K
        • Gerdts E
        • Gohlke-Bärwolf C
        • Holme I
        • Kesäniemi YA
        • Malbecq W
        • Nienaber CA
        • Ray S
        • Skjaerpe T
        • Wachtell K
        • Willenheimer R
        • SEAS Investigators
        Intensive lipid lowering with simvastatin and ezetimibe in aortic stenosis.
        N Engl J Med. 2008; 359: 1343-1356
        • Otto CM
        • Burwash IG
        • Legget ME
        • Munt BI
        • Fujioka M
        • Healy NL
        • Kraft CD
        • Miyake-Hull CY
        • Schwaegler RG.
        Prospective study of asymptomatic valvular aortic stenosis. Clinical, echocardiographic, and exercise predictors of outcome.
        Circulation. 1997; 95: 2262-2270
        • Pawade TA
        • Newby DE
        • Dweck MR.
        Calcification in aortic stenosis: the skeleton key.
        J Am Coll Cardiol. 2015; 66: 561-577
        • Kamath AR
        • Pai RG.
        Risk factors for progression of calcific aortic stenosis and potential therapeutic targets.
        Int J Angiol. 2008; 17: 63-70
        • Salinger T
        • Hu K
        • Liu D
        • Taleh S
        • Herrmann S
        • Oder D
        • Gensler D
        • Müntze J
        • Ertl G
        • Lorenz K
        • Frantz S
        • Weidemann F
        • Nordbeck P.
        Association between comorbidities and progression of transvalvular pressure gradients in patients with moderate and severe aortic valve stenosis.
        Cardiol Res Pract. 2018; 20183713897
        • Tafciu E
        • Mandoli GE
        • Santoro C
        • Setti M
        • d'Andrea A
        • Esposito R
        • Bandera F
        • Evola V
        • Malagoli A
        • Cameli M
        • Benfari G
        Working Group of Echocardiography of the Italian Society of Cardiology. The progression rate of aortic stenosis: key to tailoring the management and potential target for treatment.
        J Cardiovasc Med (Hagerstown). 2021; 22: 806-812
        • Nishimura RA
        • Otto CM
        • Bonow RO
        • Carabello BA
        • Erwin JP
        • Guyton RA
        • O'Gara PT
        • Ruiz CE
        • Skubas NJ
        • Sorajja P
        • Sundt TM
        • Thomas JD
        • ACC/AHA Task Force Members
        2014 AHA/ACC guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
        Circulation. 2014; 129: 2440-2492
        • Baumgartner H
        • Hung J
        • Bermejo J
        • Chambers JB
        • Edvardsen T
        • Goldstein S
        • Lancellotti P
        • LeFevre Jr, M
        • Miller F
        • Otto CM
        Recommendations on the echocardiographic assessment of aortic valve stenosis: a focused update from the European Association of Cardiovascular Imaging and the American Society of Echocardiography.
        Eur Heart J Cardiovasc Imaging. 2017; 18: 254-275
        • Baumgartner H
        • Hung J
        • Bermejo J
        • Chambers JB
        • Evangelista A
        • Griffin BP
        • Iung B
        • Otto CM
        • Pellikka PA
        • Quiñones M
        American Society of Echocardiography, European Association of Echocardiography. Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice.
        J Am Soc Echocardiogr. 2009; 22: 1-23
        • Lang RM
        • Badano LP
        • Mor-Avi V
        • Afilalo J
        • Armstrong A
        • Ernande L
        • Flachskampf FA
        • Foster E
        • Goldstein SA
        • Kuznetsova T
        • Lancellotti P
        • Muraru D
        • Picard MH
        • Rietzschel ER
        • Rudski L
        • Spencer KT
        • Tsang W
        • Voigt JU.
        Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging.
        Eur Heart J Cardiovasc Imaging. 2015; 16: 233-270
        • Lancellotti P
        • Tribouilloy C
        • Hagendorff A
        • Popescu BA
        • Edvardsen T
        • Pierard LA
        • Badano L
        • Zamorano JL
        Scientific Document Committee of the European Association of Cardiovascular Imaging. Recommendations for the echocardiographic assessment of native valvular regurgitation: an executive summary from the European Association of Cardiovascular Imaging.
        Eur Heart J Cardiovasc Imaging. 2013; 14: 611-644
        • Rudski LG
        • Lai WW
        • Afilalo J
        • Hua L
        • Handschumacher MD
        • Chandrasekaran K
        • Solomon SD
        • Louie EK
        • Schiller NB.
        Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography.
        J Am Soc Echocardiogr. 2010; 23: 685-713
        • Kebed K
        • Sun D
        • Addetia K
        • Mor-Avi V
        • Markuzon N
        • Lang RM.
        Progression of aortic stenosis and echocardiographic criteria for its severity.
        Eur Heart J Cardiovasc Imaging. 2020; 21: 737-743
        • Lancellotti P
        • Magne J
        • Dulgheru R
        • Clavel MA
        • Donal E
        • Vannan MA
        • Chambers J
        • Rosenhek R
        • Habib G
        • Lloyd G
        • Nistri S
        • Garbi M
        • Marchetta S
        • Fattouch K
        • Coisne A
        • Montaigne D
        • Modine T
        • Davin L
        • Gach O
        • Radermecker M
        • Liu S
        • Gillam L
        • Rossi A
        • Galli E
        • Ilardi F
        • Tastet L
        • Capoulade R
        • Zilberszac R
        • Vollema EM
        • Delgado V
        • Cosyns B
        • Lafitte S
        • Bernard A
        • Pierard LA
        • Bax JJ
        • Pibarot P
        • Oury C
        Outcomes of patients with asymptomatic aortic stenosis followed up in heart valve clinics.
        JAMA Cardiol. 2018; 3: 1060-1068
        • Nkomo VT
        • Gardin JM
        • Skelton TN
        • Gottdiener JS
        • Scott CG
        • Enriquez-Sarano M.
        Burden of valvular heart diseases: a population-based study.
        Lancet. 2006; 368: 1005-1011
        • Eveborn GW
        • Schirmer H
        • Heggelund G
        • Lunde P
        • Rasmussen K.
        The evolving epidemiology of valvular aortic stenosis. The Tromsø study.
        Heart. 2013; 99: 396-400
        • Palta S
        • Pai AM
        • Gill KS
        • Pai RG.
        New insights into the progression of aortic stenosis: implications for secondary prevention.
        Circulation. 2000; 101: 2497-2502
        • Peter M
        • Hoffmann A
        • Parker C
        • Lüscher T
        • Burckhardt D.
        Progression of aortic stenosis. Role of age and concomitant coronary artery disease.
        Chest. 1993; 103: 1715-1719
        • Ngo MV
        • Gottdiener JS
        • Fletcher RD
        • Fernicola DJ
        • Gersh BJ.
        Smoking and obesity are associated with the progression of aortic stenosis.
        Am J Geriatr Cardiol. 2001; 10: 86-90
        • Wagner S
        • Selzer A.
        Patterns of progression of aortic stenosis: a longitudinal hemodynamic study.
        Circulation. 1982; 65: 709-712
        • Samad Z
        • Sivak JA
        • Phelan M
        • Schulte PJ
        • Patel U
        • Velazquez EJ.
        Prevalence and outcomes of left-sided valvular heart disease associated with chronic kidney disease.
        J Am Heart Assoc. 2017; 6e006044
        • Perkovic V
        • Hunt D
        • Griffin SV
        • Md du Plessis
        • Becker GJ
        Accelerated progression of calcific aortic stenosis in dialysis patients.
        Nephron Clin Pract. 2003; 94: c40-c45
        • Kearney LG
        • Ord M
        • Buxton BF
        • Matalanis G
        • Patel SK
        • Burrell LM
        • Srivastava PM.
        Progression of aortic stenosis in elderly patients over long-term follow up.
        Int J Cardiol. 2013; 167: 1226-1231
        • Freeman RV
        • Otto CM.
        Spectrum of calcific aortic valve disease: pathogenesis, disease progression, and treatment strategies.
        Circulation. 2005; 111: 3316-3326
        • Piper C
        • Bergemann R
        • Schulte HD
        • Koerfer R
        • Horstkotte D.
        Can progression of valvar aortic stenosis be predicted accurately?.
        Ann Thorac Surg. 2003; 76: 676-680
        • Bahler RC
        • Desser DR
        • Finkelhor RS
        • Brener SJ
        • Youssefi M.
        Factors leading to progression of valvular aortic stenosis.
        Am J Cardiol. 1999; 84: 1044-1048
        • Tastet L
        • Tribouilloy C
        • Maréchaux S
        • Vollema EM
        • Delgado V
        • Salaun E
        • Shen M
        • Capoulade R
        • Clavel MA
        • Arsenault M
        • Bédard É
        • Bernier M
        • Beaudoin J
        • Narula J
        • Lancellotti P
        • Bax JJ
        • Généreux P
        • Pibarot P.
        Staging cardiac damage in patients with asymptomatic aortic valve stenosis.
        J Am Coll Cardiol. 2019; 74: 550-563