Asymptomatic Severe Aortic Stenosis in the Elderly

• Published in: JACC. Cardiovascular imaging Vol. 10; no. 1; pp. 43 - 50
• Main Authors: Zilberszac, Robert, MD, Gabriel, Harald, MD, Schemper, Michael, PhD, Laufer, Günther, MD, Maurer, Gerald, MD, Rosenhek, Raphael, MD
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 2017
• Subjects: Age Factors; Aged; Aged, 80 and over; aortic stenosis; Aortic Valve - diagnostic imaging; Aortic Valve - pathology; Aortic Valve - physiopathology; Aortic Valve - surgery; aortic valve replacement; Aortic Valve Stenosis - diagnostic imaging; Aortic Valve Stenosis - mortality; Aortic Valve Stenosis - physiopathology; Aortic Valve Stenosis - surgery; Asymptomatic Diseases; Calcinosis - diagnostic imaging; Calcinosis - mortality; Calcinosis - physiopathology; Calcinosis - surgery; Cardiovascular; Comorbidity; Disease Progression; Disease-Free Survival; Echocardiography, Doppler; Female; Heart Valve Prosthesis Implantation - adverse effects; Heart Valve Prosthesis Implantation - mortality; Hemodynamics; Humans; Kaplan-Meier Estimate; Male; Mobility Limitation; Proportional Hazards Models; Prospective Studies; Risk Factors; Severity of Illness Index; Time Factors; Treatment Outcome; valvular heart disease; coronary artery disease; NYHA; transcatheter aortic valve implantation; peak aortic jet velocity; aortic valve replacement; CI; CAD; TAVR; New York Heart Association; AS; CCS; aortic stenosis; NT-proBNP; HVC; Canadian Cardiovascular Society; heart valve clinic; valvular heart disease; AV-Vel; confidence interval; AVR; N-terminal pro–B-type natriuretic peptide
• ISSN: 1936-878X; 1876-7591
• DOI: 10.1016/j.jcmg.2016.05.015

Abstract Objectives This study sought to assess the natural history and optimal timing of surgery in elderly patients with severe asymptomatic aortic stenosis (AS). Background AS is increasingly diagnosed in an aging population, and large numbers of elderly patients are undergoing aortic valve procedures. However, the average age of patients represented in most natural history studies on AS is between 60 and 70 years. Methods A total of 103 consecutive patients >70 years of age (51 female; mean age 77 ± 5 years) with asymptomatic severe AS (peak aortic jet velocity [AV-Vel] 4.7 ± 0.6 m/s) were prospectively followed. Results During follow-up, 91 events occurred, including an indication for aortic valve replacement in 82 patients and cardiac deaths in 9, respectively. Event-free survival was 73%, 43%, 23%, and 16% at 1, 2, 3, and 4 years, respectively. Physical mobility was impaired in 29% of the patients, and symptom onset was severe (New York Heart Association functional class ≥III) in 43% of those who developed symptoms. Patients with AV-Vel ≥5.0 m/s had event-free survival rates of 21% and 6% at 2 and 4 years, respectively, compared with 57% and 23% for patients with AV-Vel <5.0 m/s (p < 0.001). Seventy-one patients underwent aortic valve replacement, and post-operative survival was 89% and 77% after 1 and 3 years, respectively. Conclusions In elderly patients with severe but asymptomatic AS, mild symptoms may be difficult to detect, particularly when mobility is impaired and severe symptom onset is common, warranting close clinical follow-up. Furthermore, a very high event rate can be expected, and cardiac deaths are not infrequent. Thus, elective aortic valve procedures may be considered in selected elderly patients at low procedural risk.