Reasons for Nonadherence to Guidelines for Aortic Valve Replacement in Patients With Severe Aortic Stenosis and Potential Solutions

• Published in: The American journal of cardiology Vol. 105; no. 9; pp. 1339 - 1342
• Main Authors: Freed, Benjamin H., MD, Sugeng, Lissa, MD, Furlong, Kathleen, BSN, Mor-Avi, Victor, PhD, Raman, Jaishankar, MD, PhD, Jeevanandam, Valluvan, MD, Lang, Roberto M., MD
• Format: Journal Article
• Language: English
• Published: New York, NY Elsevier Inc 01.05.2010; Elsevier; Elsevier Limited
• Subjects: Adult; Aged; Aged, 80 and over; Aortic Valve Stenosis - diagnosis; Aortic Valve Stenosis - mortality; Aortic Valve Stenosis - surgery; Biological and medical sciences; Blood vessels; Cardiology; Cardiology. Vascular system; Cardiovascular; Cardiovascular disease; Decision Making; Echocardiography; Endocardial and cardiac valvular diseases; Female; Follow-Up Studies; Guideline Adherence; Heart; Heart surgery; Heart Valve Prosthesis Implantation - methods; Heart Valve Prosthesis Implantation - standards; Humans; Male; Medical sciences; Middle Aged; Practice Guidelines as Topic; Retrospective Studies; Severity of Illness Index; Survival Rate; Time Factors; Treatment Outcome; Ultrasonic imaging; United States - epidemiology; United States; Human; Aortic stenosis; Cardiovascular disease; Patient; Replacement; Potential; Recommendation; Organ preservation; Cardiac valvular disease; Circulatory system; Cardiology; Severe; Aortic valve; Solution
• ISSN: 0002-9149; 1879-1913
• DOI: 10.1016/j.amjcard.2009.12.056

The official guidelines for the treatment of patients with valvular heart disease have given a class I indication for aortic valve replacement in patients with symptomatic, severe aortic stenosis (AS). However, many patients with symptomatic, severe AS do not undergo AVR. We sought to determine the proportion and characteristics of patients with severe AS who do not undergo AVR in a university hospital and to identify the reasons for the lack of surgical referrals, despite the class I guideline indications. We retrospectively studied consecutive patients from an academic hospital with severe AS, as determined by echocardiographic criteria. The records were reviewed for clinical presentation, co-morbidities, surgical intervention, and outcomes. Of the 106 patients with severe AS, 33 (31%) had undergone AVR and 73 (69%) had not. Of those patients without AVR, 31 (42%) were symptomatic. The most common reason the patients with symptomatic, severe AS did not undergo AVR was their symptoms were thought to be unrelated to AS. Of the 42 patients (58%) who were deemed asymptomatic, only 4% had undergone exercise stress testing. With an average follow-up of 15 months, 15 (14%) of the 73 patients who did not undergo AVR died. In patients with severe AS, physicians commonly underrecognize symptoms and overestimate the operative risk. The exercise stress tests were underused in determining which patients with severe AS were symptomatic. As a result, many patients with a class I indication for AVR, who would benefit from this life-saving intervention, do not receive it.