Sex-Specific Outcomes in Patients With Aortic Stenosis and Reduced Ejection Fraction

Women with aortic stenosis (AS) tend to be less referred for aortic valve replacement (AVR) and suffer from higher mortality risk compared to men. It is unknown if this discrepancy between sexes is also observed in the context of reduced left ventricular ejection fraction (LVEF). The objective of this study was to compare the risk of all-cause mortality between women and men with AS and reduced LVEF.

We conducted a retrospective study of all patients presenting ≥moderate AS and LVEF<50% on echocardiography at the Quebec Heart and Lung Institute (2005-2018). Using governmental registry data, we compared the odds of AVR (surgical and transcatheter) and the risk of all-cause mortality between sexes. Models were adjusted for relevant comorbidities, LVEF, AS severity and AVR as a time-dependent covariable.

Our cohort included 827 patients (38% women), aged 75 ± 11 years and with a median LVEF of 37% (quartile interval 30%-44%). After adjustment, women were less likely to undergo AVR (adjusted OR=0.58, p=0.007) and presented a higher mortality risk than men when treated conservatively (sub-distribution adjusted HR=1.39, p=0.02). There was no interaction between sex and AVR with regards to survival (p=0.13).

Among patients with significant AS and reduced LVEF, women were less likely to undergo AVR and suffered from higher mortality risk when treated conservatively, when compared to men with similar AS severity. Both sexes derived similar survival benefit from AVR. Studies are needed to better understand the potential gaps and biases explaining these findings.