- Of 200 asymptomatic patients with severe aortic stenosis, 140 (70%) adhered to guidelines of serial evaluations every 12 months over 3 years of follow up. - Patients adhering to guidelines had aortic valve replacement more frequently (47.2% vs 18.3%; p=0.001) and lower incidence of heart failure hospitalization (59.2% vs 52.6%; p=0.02) compared to non-adherent patients. - There was no difference in mortality or inpatient costs between adherent and non-adherent groups. Adherence to guidelines was associated with greater rates of aortic valve replacement and reduced heart failure hospitalization without impacting survival or costs.

1. ABSTRACT
Background: For asymptomatic
patients with severe aortic stenosis,
national practice guidelines empirically
recommend serial evaluations every 6 to
12 months. However, the benefit of this
clinical monitoring is unknown.
Methods: We examined 200 patients
with asymptomatic severe, native aortic
stenosis (81±12 yrs; 55% women).
Adherence to practice guidelines was
defined as a serial evaluation occurring
every 12±3mos until aortic valve
replacement or death. Comparisons
were performed for patients with and
without guideline adherence for major
adverse clinical events and survival.
Results: There were no significant
differences with respect to age,
morbidities, and aortic valve
hemodynamics for patients with (n=140)
and without guideline adherence (n=60).
Over a follow-up period of 3 years, aortic
valve replacement (surgical or catheter-
based therapy) was performed more
frequently in patients with guideline
adherence (47.2% vs. 18.3%; p=0.001).
Adherent patients also demonstrated
greater survival free of heart failure
hospitalization in comparison to those
without adherence (59.2% [95% CI,
50.4% to 67.9%] vs. 52.6% [39.8% to
61.3%]; p=0.02; Figure). There was no
difference in mortality nor inpatient
variable costs between those with and
without guideline adherence.
Conclusions: Adherence to practice
guidelines for serial evaluations in
patients with asymptomatic, severe aortic
stenosis is associated with greater rates
of aortic valve replacement and a lower
incidence of hospitalization for heart
failure. These beneficial outcomes occur
without an impact on survival nor on
hospitalization costs.
CORRESPONDENCE
Paul Sorajja, MD
Director, Center for Valve and
Structural Heart Disease
Minneapolis Heart Institute
Email: paul.sorajja@allina.com
Phone: (612) 863-8751
Aisha Ahmed, Christopher Han, R. Saied Farivar, Richard Bae, John Lesser, Wesley A. Pedersen, Desmond Jay, Lisa Tindell, Craig Strauss, Kevin M. Harris, Paul Sorajja
Center for Valve and Structural Heart Disease, Minneapolis Heart Institute, and the Valve Science Center, Minneapolis Heart Institute Foundation
Abbott Northwestern Hospital, Minneapolis, MN
RESULTS
Benefit of Guideline Adherence for Serial Evaluations in Patients with Severe Aortic Stenosis
0
20
40
60
80
100
Survival(%)
0 5 10 15 20 25 30 35
Follow-up Time (mos)
Non-adherent
Adherent
Survival Free of Heart Failure
Hospitalization or Death
0
20
40
60
80
100
0 5 10 15 20 25 30 35
Follow-up Time (mos)
Non-adherent
Adherent
p=0.04
Survival Free of Death, CVA, or MI
Survival(%)
0
20
40
60
80
100
0 5 10 15 20 25 30 35
Follow-up Time (mos)
Survival(%)
Adherent
Non-adherent
p=0.86
All
patients Adherent Not
adherent p
N=200 N=140 N=60
Age (yr) 78 ±12 77 ±13 81±11 0.06
Men – no. (%) 82 (41) 40 (43) 22 (37) 0.67
Hypertension – no. (%) 169 (85) 117 (84) 52 (87) 0.31
Diabetes – no. (%) 48 (24) 34 (24) 14 (25) 0.89
Atrial fibrillation – no.
(%)
66 (33) 46 (33) 20 (33) 0.95
COPD – no. (%) 29 (15) 22 (16) 7 (12) 0.46
O2-dependent 5 (3) 5 (4) 0 (0) 0.14
CAD – no. (%) 92 (46) 66 (47) 25 (47) 0.62
Prior PCI – no. (%) 44 (22) 34 (24) 10 (17) 0.23
Prior CABG – no. (%) 36 (18) 30 (21) 6 (10) 0.05
>1 prior sternotomy 16 (8) 14 (10) 2 (3) 0.11
ICD – no. (%) 8 (4) 7 (5) 1 (2) 0.27
PPM – no. (%) 19 (10) 16 (11) 3 (5) 0.16
Creatinine – g/dl 1.1± 0.4 1.09± 0.5 1.1± 0.4 0.41
Survival Free of DeathBaseline Characteristics
Events in Follow-up
All patients Adherent Not
adherent p
N=200 N=140 N=60
Aortic valve
replacement – no. (%)
77 66 11 0.0001
Myocardial infarction –
no. (%)
32 22 6 0.29
Stroke – no. (%) 29 15 14 0.04
Hospitalization for heart
failure – no. (%)
82 63 19 0.07
Death– no. (%) 24 16 8 0.70
• Ages 18 and over.
• Evaluated at the Minneapolis Heart Institute at Abbott
Northwestern Hospital between September 2007 and
December 2009.
• Asymptomatic (i.e., no history of dypsnea, chest pain, angina,
presyncope, syncope, or heart failure).
• Severe aortic stenosis, defined as aortic valve area <1.0 cm2,
on transthoracic echocardiography.
• Informed consent for research review of the medical record, in
accordance with Minnesota state law.
• Guideline adherence was defined as serial evaluations
occurring every 12±3 months until aortic valve replacement or
death.
• Patients with and without guideline adherence were compared
for clinical characteristics, symptom onset, hospitalization,
need for surgery, and costs of care.
• Statistical significance set a priori at p<0.05.
• To determine the clinical characteristics and outcomes of
asymptomatic severe aortic stenosis patients who are
adherent and non-adherent to serial evaluations every 6 to 12
months.
Study population
• The management of severe aortic stenosis in the absence of
symptoms is controversial and often challenging.
• National guidelines empirically recommend serial evaluations
every 6 to 12 months.
• However, the benefit of this clinical monitoring is unknown.
STUDY AIM
BACKGROUND
Definitions
Data analyses
METHODS
• The authors have no disclosures to
report.
• Adherence to national practice guidelines for
serial evaluations in patients with
asymptomatic, severe aortic stenosis is
associated with greater rates of aortic valve
replacement and a lower incidence of
hospitalization for heart failure.
• These beneficial outcomes occur without an
impact on overall survival nor on
hospitalization costs.
CONCLUSIONS
DISCLOSURES
• Of 200 asymptomatic patients with severe aortic
stenosis who presented to the Minneapolis Heart
Institute at Abbott Northwestern Hospital, 140
(70%) were adherent to practice guidelines over
follow-up of 3 years.
• Aortic valve replacement (surgical or catheter-
based therapy) was performed more frequently
in patients with guideline adherence (47.2% vs.
18.3%; p=0.001).
• Adherent patients also demonstrated greater
survival free of heart failure hospitalization in
comparison to those without adherence (59.2%
[95% CI, 50.4% to 67.9%] vs. 52.6% [39.8% to
61.3%]; p=0.02; Figure).
• There was no difference in mortality nor inpatient
variable costs between those with and without
guideline adherence.
SUMMARY
p=0.02
All
patients Adherent Not
adherent p
LVEF (%) 58 ±11 58 ±11 60 ±10 0.27
Mean aortic gradient
(mmHg)
4.1 ±2.4 4.2 ±2.8 3.9 ±0.9 0.56
Peak aortic velocity
(m/s)
37 ±15 37 ±14 37 ±11 0.91
AVA (cm2) 0.76 ±0.14 0.77±0.14 0.74 ±0.15 0.31
EDD (mm) 46.3 ±3.0 47.0 ±3.5 43.0 ±7.2 0.40
ESD (mm) 29.7 ±8.0 30.1 ±8.1 29.0 ±7.8 0.34
Echocardiographic Data