Bleeding Risk After Mechanical Aortic Valve Replacement Linked to Socioeconomic Status

Aortic valve replacement, heart surgery
Aortic valve replacement, heart surgery
Researchers investigated the relationship between risk for bleeding after mechanical aortic valve replacement and socioeconomic status.

Among individuals who receive mechanical aortic valve replacement (AVR), a strong association has been observed between socioeconomic status  and risk for bleeding. These findings were published in the Journal of the American College of Cardiology.

A nationwide, population-based, observational cohort study ( identifier: NCT02276950) was conducted in Sweden. The investigators sought to evaluate the effect of patients’ socioeconomic status on their risk for bleeding following mechanical AVR. All participants had received AVR with mechanical heart valve prosthesis in Sweden between January 1, 1997, and August 31, 2018, with follow-up ending on December 31, 2018. Data were obtained from the Swedish Web-system for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies register, with additional baseline characteristics obtained from the National Patient Register.

Individuals who had received any concomitant surgery on other cardiac valves were excluded from the study. To calculate household disposable income, researchers determined the mean of all yearly household disposable income figures for each patient through the calendar year of surgery.

The primary study outcome was hospitalization for a bleeding event. Secondary study outcomes included ischemic stroke and transient ischemic attack (TIA) or embolism, and cause-specific mortality (intracranial bleeding and ischemic stroke or emboli). A combined outcome, which was a composite of bleeding; stroke, TIA, or embolism; and death from any cause, was used as well.

Results of the study showed that among a total of 5974 participants, the absolute risk for bleeding after 20 years’ follow-up was 20% (95% CI, 17%-24%) in the lowest income quartile (Q1) compared with 16% (95% CI, 13%-20%) in the highest income quartile (Q4). A patient’s risk for bleeding, which decreased with increasing level of income, was significantly lower in those in income quartile 3 (hazard ratio [HR], 0.77; 95% CI, 0.60-0.99) and in those in Q4 (HR, 0.68; 95% CI, 0.50-0.92) compared with those in Q1.

Additionally, the risk for death from intracranial hemorrhage was 5 times higher in the lowest income quartile compared with the age-matched and sex-matched general Swedish population (standardized mortality ratio, 5.0; 95% CI, 3.3-7.4).

A major limitation of the study is the fact that the national registries utilized did not provide information on medication use during the follow-up period nor on recognized cardiovascular behavioral risk factors, including smoking and adherence to prescribed medication. Further, since baseline characteristics were not updated over time, possible changes were therefore not considered.

“These findings suggest suboptimal anticoagulation treatment in patients with lower [socioeconomic status] and the need for strategies to optimize anticoagulation treatment in patients with a mechanical heart valve,” the study authors wrote.

Disclosure: None of the study authors has declared affiliations with biotech, pharmaceutical, and/or device companies.  


Dalén M, Persson M, Glaser N, Sartipy U. Socioeconomic status and risk of bleeding after mechanical aortic valve replacementJ Am Coll Cardiol. Published online June 20, 2022. doi:10.1016/j.jacc.2022.04.030