Mortality and treatment delays

Treatment delays in patients with severe aortic stenosis (sAS) continue to impact outcomes. With COVID-19 putting a strain on healthcare resources — and delays in aortic stenosis (AS) treatment carrying a mortality risk that increases the longer the delay — early identification of sAS patients and timely referrals can help minimise these risks.1-3

The detrimental impact of COVID-19 on sAS referrals and patient outcomes

As many healthcare systems adjust to COVID-19 the impact of the pandemic has been felt by patients with sAS. A study in America has highlighted the risks of deferring treatment for patients with severe symptomatic aortic stenosis (ssAS).

 

On March 22, 2020, an executive New York State government order lead to the cancellation of elective procedures for 3 months.1 During this 3-month period, 27 of 77 patients (35%) experienced a cardiac event, with 24 requiring urgent TAVI for accelerated symptoms and 3 dying.1 In the 3 months preceding the order, no patients died of AS while awaiting TAVI.1

 

Minimising delays in referral for patients with sAS remains just as important today as it did before the COVID pandemic. Listen to Professor Möllmann’s insights on treating AS at the time of COVID-19.

Valvular heart Screenshot_020321
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Professor Helge Möllmann (Germany): Valvular heart disease care at time of COVID-19

2 min

ssAS lowers life expectancy if left untreated2,4

The onset of symptoms (typically angina, syncope and heart failure) with AS represents a crucial point in the natural history of the disease and is associated with a sharp decline in survival.


Mortality is poor in patients with ssAS without treatment, with survival rates as low as:2


  • 50% at 2 years and
  • 20% at 5 years
While a study of 1,005 patients with ssAS, which included 823 recommended for aortic valve replacement (AVR), showed the risk of death when waiting for treatment increased more than three-fold between 1 and 6 months:4


The authors of the study concluded that the risk of mortality while waiting for AVR (3.7% at 1 month) was equivalent for the intervention itself (3.9% 30-day mortality).4


Early referral of patients with sAS can maximise their chances of receiving timely treatment

Euro VHD II survey shines a light on current practices

The aim of VHD II survey was to analyse the actual management of valvular heart disease (VHD) in clinical practice vs recommendations within the latest clinical guidelines.3

The survey demonstrated that recommendations for interventions in symptomatic patients with severe aortic valve disease are applied more consistently compared with the previous European survey conducted in 2001.3,5

  • 79.4% (95% CI, 77.1–81.6; n=2,152) of patients with symptomatic AS and a Class I indication for intervention had one performed or scheduled

Intervention decision for patients with ssAS and Class 1

indication in 2017*3

EUROHeart_graphic 1

Intervention decision for ssAS patients aged > 75

years in 2001†5

EUROHeart_graphic 2

Intervention decision for patients with ssAS and Class 1

indication in 2017*3

Intervention decision for ssAS patients aged > 75 years in 2001†5
EUROHeart_graphic 1
EUROHeart_graphic 2

 

 

The wider availability of TAVI may partly account for this change in practice.

 

Late referral was identified as an ongoing issue, highlighting the need for increased awareness of valvular heart disease amongst general practitioners and cardiologists.3 Of the patients with AS who were referred, 37.3% were New York Heart Association class III or IV and 16.4% required hospitalisation for heart failure within the preceding year.

 

Delays in scheduled treatment were also highlighted even though prolonged waiting time for intervention is associated with increased mortality.3 Only 48.1% of patients requiring scheduled intervention for AS actually underwent treatment within 6 months.

 

The COVID-19 pandemic represents an unprecedented challenge for health care systems, emphasising that treatment delays are linked to poor prognosis outcomes for patients with ssAS. Prioritising early referrals for patients with sAS remains key.

Patients with sAS who require AVR may not always present with classical symptoms. See more on AS diagnosis and evaluation.


Intervention = TAVI or sAVR Intervention = sAVR.

References :

  • 1Ro R, et al. JAMA Network Open 2020;3(9):e2019801.
  • 2Otto CM. Heart 2000;84(2):211–218.
  • 3Iung B et al. Circulation 2019;140(14):1156–1169.
  • 4Malaisrie SC, et al. Ann Thorac Surg 2014;98(5):1564–1571.
  • 5Iung B et al. Eur Heart J 2005;26(24):2714-2720.

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References

  • 1Raddatz MA, et al. Open Heart. 2020;7(2):e001331.
  • 2Delgado V, et al. JACC Cardiovasc Imaging. 2019;12(2):267–282.
  • 3Baumgartner H, et al. Eur Heart J Cardiovasc Imaging 2017;18(3):254–275.

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