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Management of patients with severe aortic stenosis in the TAVI-era: how recent recommendations are translated into clinical practice
A. Lauten, TK. Rudolph, D. Messika-Zeitoun, J. Thambyrajah, A. Serra, E. Schulz, N. Frey, J. Maly, M. Aiello, G. Lloyd, AS. Bortone, A. Clerici, G. Delle-Karth, J. Rieber, C. Indolfi, M. Mancone, L. Belle, M. Arnold, BJ. Bouma, M. Lutz, C....
Language English Country Great Britain
Document type Journal Article, Multicenter Study, Research Support, Non-U.S. Gov't
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- MeSH
- Aortic Valve Stenosis diagnosis surgery MeSH
- Echocardiography MeSH
- Quality of Health Care * MeSH
- Humans MeSH
- Disease Management * MeSH
- Follow-Up Studies MeSH
- Prospective Studies MeSH
- Aged MeSH
- Practice Guidelines as Topic * MeSH
- Severity of Illness Index MeSH
- Transcatheter Aortic Valve Replacement standards MeSH
- Check Tag
- Humans MeSH
- Male MeSH
- Aged MeSH
- Female MeSH
- Publication type
- Journal Article MeSH
- Multicenter Study MeSH
- Research Support, Non-U.S. Gov't MeSH
OBJECTIVE: Approximately 3.4% of adults aged >75 years suffer from aortic stenosis (AS). Guideline indications for aortic valve replacement (AVR) distinguish between patients with symptomatic and asymptomatic severe AS. The present analysis aims to assess contemporary practice in the treatment of severe AS across Europe and identify characteristics associated with treatment decisions, namely denial of AVR in symptomatic patients and assignment of asymptomatic patients to AVR. METHODS: Participants of the prospective, multinational IMPULSE database of patients with severe AS were grouped according to AS symptoms, and stratified into subgroups based on assignment to/denial of AVR. RESULTS: Of 1608 symptomatic patients, 23.8% did not undergo AVR and underwent medical treatment. Denial was independently associated with multiple factors, including severe frailty (p=0.024); mitral (p=0.002) or tricuspid (p=0.004) regurgitation grade III/IV, and the presence of renal impairment (p=0.017). Of 392 asymptomatic patients, 86.5% had no prespecified indication for AVR. Regardless, 36.3% were assigned to valve replacement. Those with an indexed aortic valve area (AVA; p=0.045) or left ventricular ejection fraction (LVEF; p<0.001) below the study median; or with a left ventricular end systolic diameter above the study median (p=0.007) were more likely to be assigned to AVR. CONCLUSIONS: There may be considerable discrepancies between guideline-based recommendations and clinical practice decision-making in the treatment of AS. It appears that guidelines may not fully capture the complete clinical spectrum of patients with AS. Thus, there is a need to find ways to increase their acceptance and the rate of adoption.
4th Medical Department Hietzing Hospital Vienna Austria
Cardiology Department AKH Celle Celle Niedersachsen Germany
Centre Hospital d'Annecy Annecy France
Department for Cardiology Helios Clinic Erfurt Germany
Department of Cardiology and Angiology University of Kiel Kiel Schleswig Holstein Germany
Department of Cardiology University Hospital Erlangen Erlangen Bayern Germany
Department of Cardiothoracic Surgery Foundation IRCCS Policlinico S Matteo Pavia Italy
Division of Cardiology and URT CNR of IFC University Magna Graecia Catanzaro Calabria Italy
Edwards Lifesciences Nyon Switzerland
Edwards Lifesciences Prague Czech Republic
Institut für Pharmakologie und Präventive Medizin GmbH Cloppenburg Germany
Interventional Cardiology Unit Hospital de la Santa Creu i Sant Pau Barcelona Catalunya Spain
James Cook University Hospital Middlesbrough UK
Sapienza University of Rome Rome Italy
St Bartholomew's Hospital London UK
University of Amsterdam Amsterdam Netherlands
University of Bari Bari Puglia Italy
References provided by Crossref.org
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- $a OBJECTIVE: Approximately 3.4% of adults aged >75 years suffer from aortic stenosis (AS). Guideline indications for aortic valve replacement (AVR) distinguish between patients with symptomatic and asymptomatic severe AS. The present analysis aims to assess contemporary practice in the treatment of severe AS across Europe and identify characteristics associated with treatment decisions, namely denial of AVR in symptomatic patients and assignment of asymptomatic patients to AVR. METHODS: Participants of the prospective, multinational IMPULSE database of patients with severe AS were grouped according to AS symptoms, and stratified into subgroups based on assignment to/denial of AVR. RESULTS: Of 1608 symptomatic patients, 23.8% did not undergo AVR and underwent medical treatment. Denial was independently associated with multiple factors, including severe frailty (p=0.024); mitral (p=0.002) or tricuspid (p=0.004) regurgitation grade III/IV, and the presence of renal impairment (p=0.017). Of 392 asymptomatic patients, 86.5% had no prespecified indication for AVR. Regardless, 36.3% were assigned to valve replacement. Those with an indexed aortic valve area (AVA; p=0.045) or left ventricular ejection fraction (LVEF; p<0.001) below the study median; or with a left ventricular end systolic diameter above the study median (p=0.007) were more likely to be assigned to AVR. CONCLUSIONS: There may be considerable discrepancies between guideline-based recommendations and clinical practice decision-making in the treatment of AS. It appears that guidelines may not fully capture the complete clinical spectrum of patients with AS. Thus, there is a need to find ways to increase their acceptance and the rate of adoption.
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