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Predictors of Major Adverse Cardiovascular Events in Patients With Moderate Aortic Stenosis: Implications for Aortic
Travis Howard1, Monil Majmundar2, Shlok Sarin3
1Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH (T.H., A.K., A.A., A.K., G.W.R., S.C.H., E.H., E.G., S.R.K., R.P.).
Insights
Risk stratification for moderate aortic stenosis is crucial. Elevated NT-proBNP, diabetes, mitral valve E/e
Area of Science:
- Cardiovascular Medicine
- Cardiac Surgery
- Clinical Cardiology
Background:
- Prognosis and management of severe aortic stenosis are well-studied.
- Risk stratification and outcomes for moderate aortic stenosis remain unclear.
Purpose of the Study:
- To investigate risk factors and outcomes in patients with moderate aortic stenosis.
- To identify predictors of major adverse cardiovascular events in this patient group.
Main Methods:
- Retrospective analysis of 674 patients with moderate aortic stenosis.
- Inclusion criteria: Aortic valve area 1-1.5 cm², mean gradient 20-40 mmHg, peak velocity <4 m/s.
- Primary outcome: Major adverse cardiovascular events (progression to severe AS, heart failure hospitalization, or death).
Main Results:
- Median follow-up of 316 days; 305 patients experienced composite events.
- Independent predictors of adverse outcomes included elevated NT-proBNP, diabetes, elevated mitral valve E/e' ratio, and atrial fibrillation.
- These factors incrementally increased the risk of major adverse cardiovascular events.
Conclusions:
- Patients with moderate aortic stenosis have relatively poor short-to-medium term outcomes.
- Identified risk factors aid in stratifying patients with moderate aortic stenosis.
- Results support trials for transcatheter aortic valve replacement in this population.
Background:
Although the prognosis and management of severe aortic stenosis has been extensively studied, the risk stratification and outcomes of patients with moderate aortic stenosis remain elusive.
Methods:
This study included 674 patients from the Cleveland Clinic Health System with moderate aortic stenosis (aortic valve area, 1-1.5 cm2; mean gradient, 20-40 mm Hg; and peak velocity <4 m/s) and an NT-proBNP (N-terminal pro-B-type natriuretic peptide) level within 3 months of index diagnosis. The primary outcome of major adverse cardiovascular events (defined as the composite outcome of progression to severe aortic stenosis requiring aortic valve replacement, heart failure hospitalization, or death) was extracted from the electronic medical record.
Results:
The mean age was 75.3±12 years, and 57% were men. During a median follow-up of 316 days, the composite end point occurred in 305 patients. There were 132 (19.6%) deaths, 144 (21.4%) heart failure hospitalizations, and 114 (16.9%) patients underwent aortic valve replacement. Elevated NT-proBNP (1.41 [95% CI, 1.01-1.95]; P=0.048), diabetes (1.46 [95% CI, 1.08-1.96]; P=0.01), elevated averaged mitral valve E/e' ratio (hazard ratio, 1.57 [95% CI, 1.18-2.10]; P<0.01), and presence atrial fibrillation at the time of index echocardiogram (hazard ratio, 1.83 [95% CI, 1.15-2.91]; P=0.01) were each independently associated with an increased hazard for the composite outcome and when taken collectively, each of these factors incrementally increased risk.
Conclusions:
These results further elucidate the relatively poor short-medium term outcomes and risk stratification of patients with moderate aortic stenosis, supporting randomized trials assessing the efficacy of transcatheter aortic valve replacement in this population.
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