Outcomes of patients with calcific aortic valve disease according to the extent of cardiac damage

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Abstract
Background A staging system for aortic stenosis (AS) based upon the extent of cardiac damage has been proposed to better stratify risk and evaluate the benefit of aortic valve intervention (AVI), especially in those with moderate AS. We sought to evaluate the prognostic value of this staging system. Methods Data from initial clinically indicated echocardiograms performed between 2010 and 2018 in patients >18 years of age were extracted and linked to national outcome data. The combined primary outcome was mortality or hospitalization with heart failure. Results Amongst 24,699 patients, 513 and 920 had moderate and mild AS, respectively. In moderate AS, Stage 0 cardiac damage was present in 9.4%, Stage 1 in 53.7%, Stage 2 in 31.1%, Stage 3 in 3.2%, and Stage 4 in 2.6%. In mild AS, rates were 11.5%, 57.8%, 25.0%, 2.6%, and 3.0% for each consecutive stage. Increasing stage was associated with increased risk of the primary outcome in both moderate (HR 1.62/stage) and mild AS (HR 1.93/stage). After censoring at the time of AVI, increasing stage was also associated with mortality in moderate (HR 1.97/stage) and mild AS (HR 2.06/stage). Conclusion Stage of cardiac damage predicts prognosis in both moderate and mild AS to a similar extent. Outcomes may therefore not be fully related to the haemodynamic consequences of valve disease, and hence may not be entirely reversible after valve intervention. Revised management algorithms focusing on earlier intervention and novel treatment strategies targeting cardiac damage are needed to improve clinical outcomes in patients with AS.

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