Long-Term Prognosis Is Poor for Patients With Severe Aortic Stenosis Managed Conservatively

SAN FRANCISCO – Conservative management of asymptomatic patients with severe aortic stenosis (AS) resulted in “dismal” long-term outcomes, according to Tomohiko Taniguchi, MD, a researcher from Kyoto University Graduate School of Medicine in Kyoto, Japan. Specifically, when compared with initial aortic valve replacement (AVR), the conservative approach led to significantly higher rates of all-cause death and heart failure (HF) hospitalization.

The results of the multicenter, retrospective CURRENT AS Registry were presented at the 2015 Transcatheter Cardiovascular Therapeutics annual meeting in San Francisco and simultaneously published in the Journal of the American College of Cardiology.

“The current guidelines recommend a strategy of watchful waiting for AVR until symptoms emerge in asymptomatic patients with severe AS, except for several subgroups of patients, such as those with left ventricular dysfunction or very severe AS,” Taniguchisaid during a TCT press conference. “However, this recommendation was based on previous small, single-center studies evaluating symptoms and/or AVR, but not mortality as the outcome measures. There is no previous large-scale, multicenter study comparing the initial AVR strategy with the conservative strategy.”

This led Taniguchi and colleagues to design the CURRENT AS Registry, which enrolled 3815 consecutive patients with severe AS from 27 centers in Japan between 2003 and 2011. Of the 1808 patients who were asymptomatic, 291  received initial AVR and 1517 received conservative management.

The researchers created a propensity-score matched cohort of 582 patients—291 receiving initial AVR (mean age, 71.6 years) and 291 receiving conservative management (mean age, 73.1 years)—to serve as the main analysis set for the current study.

The primary outcome measures were all-cause death and HF hospitalization, and the secondary outcomes were cardiovascular death, non-cardiovascular death, sudden death and emerging AS-related symptoms.

Median follow-up was 3.7 years and the 2-year follow-up rate was 90%.

During follow-up, 41% of the conservative arm underwent AVR.

Results indicated that compared with the initial AVR group, those who received conservative management had significantly higher rates of all-cause death (26.4% vs. 15.4%; P=.009) and HF hospitalization (19.9% vs. 3.8%; P<.001), as well as all the secondary endpoints with the exception of non-cardiovascular death.

Taniguchi noted several limitations of the study, however, including its retrospective design, variable patient follow-up, selection bias and residual confounding. 

“Despite these limitations, we can conclude that the long-term outcome of asymptomatic patients with severe AS was dismal when managed conservatively in … clinical practice, which might be substantially improved by the initial AVR strategy,” Taniguchi said.

Disclosures: This study was funded by the Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine.

References

1. Taniguchi T et al. Initial Surgical versus Conservative Strategies in Patients with Asymptomatic Severe Aortic Stenosis. J Am Coll Cardiol. 2015; doi:10.1016/j.jacc.2015.10.001.

2. Taniguchi T et al. Late-Breaking Trials and First Report Investigations IV. Presented at: 27^th Annual Transcatheter Cardiovascular Therapeutics scientific symposium; October 10-15, 2015; San Francisco.