MINNEAPOLIS, MN — Guideline-recommended serial evaluation of patients with asymptomatic severe aortic stenosis is associated with improved survival and lower heart-failure hospital admissions, in a new study[1].
Results of the retrospective review showed patients who were closely monitored were also more likely to undergo aortic-valve replacement (AVR) and to receive that replacement earlier.
“I think our paper really shows that if you follow these patients closely—even if you think you shouldn’t operate on asymptomatic patients, which we don’t have yet convincing data to support—but if you follow them closely and make that decision with a cardiologist, there is a survival benefit and a significant reduction in rehospitalization,” said senior author Dr Mario Gössl (Valve Science Center, Minneapolis Heart Institute, MN).
Their findings were published online September 6, 2017 as a brief report in JAMA Cardiology.
In an interview with theheart.org | Medscape Cardiology, Gössl explained that the result of close follow-up was not that asymptomatic patients were sent for AVR but that the appearance of symptoms was detected early.
“It has been shown that when you follow aortic-stenosis patients who are asymptomatic for a year, many of them will turn symptomatic, but it often requires a careful clinical examination to detect that, because the symptoms may not always be the typical shortness of breath or chest pain.”
He added that patients are often reticent to admit to symptoms to their family members and physicians.
“Very often, in my experience, when you ask about symptoms the patient says no, but the family member’s face tells a different story, and when you ask further someone might say something like, ‘Well, how come for the past year you don’t want to go upstairs anymore to the bedroom and you’d rather sleep downstairs?’ ” Gössl said.
This retrospective study could not definitively show how guideline adherence improved outcomes, but Gössl noted that it was not echocardiography changes or other clinical factors that triggered the referral for AVR but the appearance of symptoms.
Of note, while the nonrandomized nature of the study is a stated limitation, there were no significant baseline differences between groups, and multivariate analyses to account for potential selection bias revealed no diminishment of benefit seen for guideline-adherent patients.
For this analysis, the researchers retrospectively studied 300 patients (47.7% male, mean age 78.6 years) with asymptomatic severe aortic stenosis and preserved left ventricular function who were followed in the ambulatory clinic at the Minneapolis Heart Institute at Abbott Northwestern Hospital.
Survival and clinical event rates were compared for those who received serial evaluations every 12±6 months until aortic-valve replacement or death and those who did not.
Over a median follow-up of 4.5 years, 202 patients were deemed guideline adherent and 98 patients were not. Baseline characteristics, including age, insurance status, left ventricular function, severity of aortic stenosis, and concomitant valvular heart disease, were similar between groups.
Despite these baseline similarities, surgical- or catheter-based AVR was performed in 54% of those who were followed more closely, as compared with 19.4% of those followed less often.
As well, the median time to performance of AVR was significantly less in those who were followed more closely, at 2.2 years vs 3.5 years (P<0.001).
Mortality in the overall cohort was 36.7%, with a median time to death of 3.4 years. All-cause mortality was significantly higher for guideline-nonadherent patients (hazard ratio [HR] 1.57, P<0.001), as was MI (HR 1.87, P=0.04), stroke (HR 1.94, P=0.04), and heart-failure hospitalization (HR 1.66, P=0.001).
Four-year survival free of a combined end point of death and heart-failure hospitalization was 38.7% for adherent patients and 23.3% for nonadherent patients (P<0.001), a difference that remained significant after multivariate adjustment (adjusted HR 1.54, P=0.03).
Lending Support to Empirical Guidelines
The findings lend weight to 2014 American Heart Association/American College of Cardiology guidelines for the management of patients with valvular heart disease that empirically recommend following these patients every 6 to 12 months.
“There are not many trials in this area of medicine and so there are a lot of level-of-evidence-C recommendations, which means they are based on clinical consensus and not a lot of data,” said Robert O Bonow, MD (Northwestern University Feinberg School of Medicine, Chicago, IL), commenting on the findings for theheart.org | Medscape Cardiology.
Bonow is a long-time contributor to the valvular heart-disease guidelines and the editor in chief of JAMA Cardiology.
“This was a small, single-center study, but it is helpful because it supports what had been a class I, level of evidence C recommendation, and now we have evidence that maybe that recommendation is a good one.”
It will take at least one confirmatory study to raise the level of evidence to B, but the study also shows that “sometimes it’s not the test you’re doing, but that you’re talking to the patient and picking up on their symptom status. They may not realize that they are more short of breath or they’re exercising less, so seeing a doctor really matters,” Bonow said.
Dr Gössl reported no relevant financial relationships. Disclosures for the coauthors are listed in the paper.
For more from theheart.org | Medscape Cardiology, follow us on Twitter and Facebook.
Tidak ada komentar:
Posting Komentar