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. 2024 Mar 6;3(4):100879.
doi: 10.1016/j.jacadv.2024.100879. eCollection 2024 Apr.

Prediction of the Individual Aortic Stenosis Progression Rate and its Association With Clinical Outcomes

Constantijn S Venema  1 , Kees H van Bergeijk  1 , Demetra Hadjicharalambous  1 , Theodora Andreou  1 , Jasper Tromp  1   2 , Laura Staal  1 , Jan A Krikken  1 , Hindrik W van der Werf  1 , Ad F M van den Heuvel  1 , Yvonne L Douglas  1 , Erik Lipsic  1 , Adriaan A Voors  1 , Joanna J Wykrzykowska  1
Affiliations

Prediction of the Individual Aortic Stenosis Progression Rate and its Association With Clinical Outcomes

Constantijn S Venema et al. JACC Adv. .

Abstract

Background: The progression rate of aortic stenosis differs between patients, complicating clinical follow-up and management.

Objectives: This study aimed to identify predictors associated with the progression rate of aortic stenosis.

Methods: In this retrospective longitudinal single-center cohort study, all patients with moderate aortic stenosis who presented between December 2011 and December 2022 and had echocardiograms available were included. The individual aortic stenosis progression rate was calculated based on aortic valve area (AVA) from at least 2 echocardiograms performed at least 6 months apart. Baseline factors associated with the progression rate of AVA were determined using linear mixed-effects models, and the association of progression rate with clinical outcomes was evaluated using Cox regression.

Results: The study included 540 patients (median age 69 years and 38% female) with 2,937 echocardiograms (median 5 per patient). Patients had a linear progression with a median AVA decrease of 0.09 cm2/y and a median peak jet velocity increase of 0.17 m/s/y. Rapid progression was independently associated with all-cause mortality (HR: 1.77, 95% CI: 1.26-2.48) and aortic valve replacement (HR: 3.44, 95% CI: 2.55-4.64). Older age, greater left ventricular mass index, atrial fibrillation, and chronic kidney disease were associated with a faster decline of AVA.

Conclusions: AVA decreases linearly in individual patients, and faster progression is independently associated with higher mortality. Routine clinical and echocardiographic variables accurately predict the individual progression rate and may aid clinicians in determining the optimal follow-up interval for patients with aortic stenosis.

Keywords: aortic stenosis; risk prediction; structural heart disease; transcatheter aortic valve replacement; valvular heart disease.

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Conflict of interest statement

The authors have reported that they have no relationships relevant to the contents of this paper to disclose.PERSPECTIVESCOMPETENCY IN MEDICAL KNOWLEDGE: Aortic stenosis progression rate is heterogeneous and follows a linear trajectory in the majority of patients. Rapid progression is independently associated with all-cause mortality and aortic valve replacement. Older age, greater left ventricular mass index, atrial fibrillation, and chronic kidney disease at the baseline diagnosis of aortic stenosis are associated with a faster decline in the aortic valve area. TRANSLATIONAL OUTLOOK: Our model provides a step toward the development of a patient-specific aortic stenosis progression rate calculator to identify patients at risk for rapid progression at baseline and to tailor follow-up intervals, which becomes increasingly important with the rising worldwide burden of valvular heart disease. Furthermore, our study could help identify patients for future trials investigating therapies to delay aortic stenosis progression.

Figures

None
Graphical abstract
Figure 1
Figure 1
Study Flow Chart AS = aortic stenosis; AVA = aortic valve area; AVR/P = aortic valve replacement/valvuloplasty.
Figure 2
Figure 2
Association of Rate of Aortic Stenosis Progression With Long-Term Clinical Outcomes Up to 10 Years (A) All-cause mortality; (B) cardiovascular mortality; (C) heart failure hospitalization; (D) composite of heart failure hospitalization and cardiovascular death; and (E) aortic valve replacement. Curves depict event-free survival for slow and rapid progression of aortic stenosis adjusted in multivariable analysis, and time is presented in years. AVR = aortic valve replacement; CV death = cardiovascular death; HR = hazard ratio.
Central Illustration
Central Illustration
Progression of Aortic Stenosis Severity Over Time in 2 Different Patients With Equivalent Baseline Severity Patient 1 has rapid progression and is an elderly individual of 80 years old with a history of atrial fibrillation and chronic kidney disease, and has left ventricular hypertrophy (elevated LVMI). We found that rapid progression is associated with increased mortality, aortic valve replacement, and heart failure admissions. Patient 2 is 60 years old with a history of COPD and has slow progression of aortic stenosis. The equation at the bottom of the figure depicts the model calculation to predict the annual decline in aortic valve area, with age per 10-year increase, LVMI per 50 g/m2 increase, and SVI per 10 mL/m2 increase. AF = atrial fibrillation; AVA = aortic valve area; AVR = aortic valve replacement; CKD = chronic kidney disease (estimated glomerular filtration rate <60 ml/min/1.73 m2); COPD = chronic obstructive pulmonary disease; HF = heart failure; LVMI = left ventricular mass index; SVI = stroke volume index.
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