Hemodynamic progression and outcome of asymptomatic aortic stenosis in primary care

The prognostic relevance of a rapid rate of hemodynamic progression of aortic stenosis (AS) has been predominantly investigated in tertiary centers. We reviewed the clinical and echocardiographic data from 153 asymptomatic patients with AS (age 77 ± 9 years; 65% men), with normal left ventricular function and paired echocardiograms ≥4 months apart (mean 2.9 ± 2.1 years), evaluated in a nonreferral echocardiographic laboratory. The severity of AS was graded by the peak aortic velocity (Vmax) and progression was classified as slow or fast according to a cutoff value of 0.3 m/s increase annually. The end points were all-cause mortality and a composite of all-cause mortality and aortic valve replacement (AVR). At baseline, 135 patients (88%) had mild-to-moderate and 18 (12%) severe AS. Of the 153 patients, 49 (32%) showed fast progression (0.61 ± 0.32 m/s/yr) and 104 (68%) had slow progression (0.10 ± 0.16 m/s/yr). Among the 144 patients (94%) with clinical follow-up data, 40 died and 48 underwent AVR. The mortality rate was greater than that of the general population (p <0.001). On multivariate analysis, the independent predictors of mortality were the yearly change in Vmax (hazard ratio [HR] 13.352 per m/s increase, 95% confidence interval [CI] 5.136 to 34.713, p <0.001) and age (HR 1.122 per year, 95% CI 1.0728 to 1.735, p <0.001). The predictors of the composite end point of death and AVR were the yearly change in Vmax (HR 12.307, 95% CI 6.024 to 25.140, p <0.001) and Vmax on the initial echocardiogram (HR 2.684, 95% CI 1.921 to 3.750, p <0.001). In conclusion, primary care patients with asymptomatic AS are usually elderly and frequently develop rapid hemodynamic progression, which independently predicts, not only AVR, but also overall mortality.