Valvular heart disease

Uncovering the treatable burden of
severe aortic stenosis in the UK
Geoffrey A Strange ‍ ‍,1,2 Simon Stewart ‍ ‍,3,4 Nick Curzen ‍ ‍,5 Simon Ray ‍ ‍,6
Simon Kendall,7 Peter Braidley,8 Keith Pearce,9 Renzo Pessotto,10
David Playford ‍ ‍,1 Huon H Gray11► Additional supplemental
material is published online only.
To view, please visit the journal
online (http://​dx.d​ oi.​org/​10.​1136/o​ penhrt-​2021-0​ 01783).

To cite: Strange GA, Stewart S,
Curzen N, et al. Uncovering thetreatable burden of severe aortic
stenosis in the UK. Open Heart
2022;9:e001783. doi:10.1136/
openhrt-2021-001783
Received 13 July 2021
Accepted 1 November 2021

© Author(s) (or theiremployer(s)) 2022. Re-­use
permitted under CC BY-­NC. No
commercial re-­use. See rights
and permissions. Publishedby BMJ.
For numbered affiliations see
end of article.
Correspondence to
Dr Geoffrey A Strange; ​gstrange@n​ eda.​net.​au

ABSTRACT

Objective To estimate the population prevalence andtreatable burden of severe aortic stenosis (AS) in the UK.
Methods We adapted a contemporary model of the
population profile of symptomatic and asymptomatic
severe AS in Europe and North America to estimate thenumber of people aged ≥55 years in the UK who might
benefit from surgical aortic valve replacement (SAVR) or
transcatheter aortic valve implantation (TAVI).
Results With a point prevalence of 1.48%, we estimatethat 291 448 men and women aged ≥55 years in the UK
had severe AS in 2019. Of these, 68.3% (199 059, 95% CI
1 77 201 to 221 355 people) would have been symptomaticand, therefore, more readily treated according to theirsurgical risk profile; the remaining 31.7% of cases(92 389, 95% CI 70 093 to 144 247) being asymptomatic.
Based on historical patterns of intervention, 58.4%(116 251, 95% CI 106 895 to 1 25 606) of the 199 059
symptomatic cases would qualify for SAVR, with 7208
(95% CI 7091 to 7234) being assessed as being in ahigh, preoperative surgical risk category. Among theremaining 41.6% (82 809, 95% CI 73 453 to 92 164) ofcases potentially unsuitable for SAVR, an estimated 61.7%(51 093, 95% CI 34 780 to 67 655) might be suitable for
TAVI. We estimate that 172 859 out of 291 448 prevalent
cases of severe AS (59.3%) will subsequently die within
5 years without proactive management.
Conclusions These data suggest a high burden of
severe AS in the UK requiring surgical or transcatheter
intervention that challenges the ongoing capacity of
the National Health Service to meet the needs of thoseaffected.

INTRODUCTION
Aortic stenosis (AS) is one of the mostcommon acquired forms of heart valve diseaserequiring clinical intervention.1 2 As highlighted by the OxVALVE Study,3 a significant
portion of the UK population (1.3% of theircohort of individuals age ≥65 years had undiagnosed AS) will remain undetected during
their lifetime or experience a ‘late’ diagnosis
when their condition reaches an advanced,
symptomatic stage.4 The prevalence of AS
correlates strongly with advancing age and isa major cause of death among older individuals.1 2 For example, within the large National

Key questions
What is already known about this subject?
► Severe aortic stenosis (AS) has a high mortality ifleft untreated.
► The number of individuals who might benefit fromtreatment in the UK is uncertain, although anticipated to be large.

What does this study add?
► This study provides robust estimates of the overallburden of severe AS across the UK and the indicative
number of individuals who would benefit from surgical or transcatheter interventions.

How might this impact on clinical practice?
► These data will assist health administrators andclinicians to determine the potential near-­term demand for aortic valve interventions and, importantly,
whether healthcare services are currently configured to address current to future demands.

Echocardiography Database of Australia(NEDA) patient cohort, the incidence of AS
rose eightfold from 5 to 40 cases/1000 person-­years among those aged <30 years to >80 years(overall incidence of ~18 cases/1000 person-­years).5 Within this same cohort, the proportion of individuals who died with severe AS
rose from 3.9% in those aged >65 years to
6.1% in those aged >85 years.6 Unfortunately,
given the logistics of definitive screening withechocardiography, population studies suchas the OxVALVE Study3 are scarce. Consequently, the natural history and subsequentdisease burden of AS is often described fromthe perspective of those who are already diagnosed and receiving definitive treatment.
Of concern, in the context of a probable‘iceberg’ of largely undetected and untreatedcases of AS within progressively ageing high-­
income countries like the UK,7 is the highmortality associated with untreated severe
AS, especially once symptoms develop.8 The
mortality in such patients is reported to be as
high as 50% at 2 years and 97% at 5 years.9
Poor survival rates associated with the full

Strange GA, et al. Open Heart 2022;9:e001783. doi:10.1136/openhrt-2021-001783

1Open Heart: first published as 10.1136/openhrt-2021-001783 on 26 January 2022. Downloaded from http://openheart.bmj.com/ on September 22, 2024 by guest. Protected by copyright.

Open access

spectrum of AS within the large, unselected NEDA cohort6
reaffirmed the potential to proactively identify and treat
more individuals with severe AS.10 In common with the
evolving trial evidence around aortic valve replacement(AVR),2 within the same cohort, the survival benefits
conferred by successful AVR were striking.11 Such data
highlight the potential for substantial public health benefits of earlier detection of AS, using the stethoscope andechocardiography, and subsequent rapid access to heart
valve centres/clinics.2 This latent potential to increase
the detection of AS was further highlighted in the NHS
England’s Long-­Term Plan 2019.12 However, until moredefinitive population studies of AS are conducted, it isdifficult to accurately assess the size of the treatable population with severe AS and thereby plan clinical services toensure potentially life-­saving treatments are applied.13 14
STUDY AIMS
The primary aim of this study was to determine how many
people might be expected to need evidence-­based treatment for severe AS in the UK in the near term based on
expert guidelines for its optimal diagnosis and management.2 Specifically, we first sought to apply age-­specificestimates of the prevalence of severe AS within the known
UK population aged 55 years or older to calculate thelikely number of individuals affected by severe AS overall(prevalent cases). We further sought to estimate how
many individuals could be immediately identifiable/
detected based on the presence of concurrent symptoms (diagnosed/treated cases). Finally, based on thehistorical application of surgical aortic valve replacement(SAVR) versus transcatheter aortic valve implantation(TAVI) for severe AS according to surgical risk (based oncomposite data derived from the UK, Europe and North
America),15 16 we further aimed to quantify the likely
demand for surgical services if all cases of severe AS weredetected (surgical caseload).

constructed. The sequential distribution of cases throughthe flowchart was informed by meta-­analyses with beta
distributions used at each step (using 10 000 Monte Carlosimulations) to derive the most accurate point estimates(with 95% confidence intervals, CIs) for each sequence.
Critically, local reimbursement policies were not considered in determining who might or might not be treatedwith surgical intervention.16 Notwithstanding the rapidly
evolving literature around the choice between SAVR
versus TAVI and, indeed, the pattern of surgical risk thatwill undoubtedly influence future treatment pathways,2
this model provided a robust framework for estimating
the treatable burden of severe AS in the UK.
Summary model
Figure 1 summarises the key steps applied to generate theestimates provided in this report with consideration of
the UK population structure, the underlying prevalenceof severe AS, their symptomatic status and their potential treatment based on their likely surgical risk profile—noting that each identified prevalent case is accounted
for in the flowchart. Each of these steps (and their sourcedata) are described below.
UK population data
To determine how many people within the UK are at
risk of developing severe AS (our denominator/at risk
population group), we first obtained age-­
specific andsex-­specific population data for the calendar year 2019from the UK Office of National Statistics (online supplemental figure 1).18 In that year, of the approximate
66 million people living in the UK, 30% were aged ≥55
years (20.1 million people). We also collated these data
separately for England, Wales, Scotland and Northern
Ireland to generate specific estimates for each geopolitical region.

METHODS
A pragmatic approach to estimate the treatable burdenof disease imposed by severe AS in the UK was applied
using similar methods previously used to derive whatproved to be an accurate forecast of the contemporary
and projected burden of heart failure in the UK.17 The
same broad methods were also applied to an equivalent study of the treatable burden of AS in Australia.7
The primary basis for this study (in respect to providingAS-­specific data) was two meta-­analyses of AS that systematically reviewed and analysed the relevant public healthto clinical literature to build contemporary models of thelikely burden and treatment of severe AS.15 16 The mostrecent of these reports synthesised data from 9723 casesof severe AS from 7 studies (predominantly from North
America and Europe/UK).16 A decision-­making flowchartof severe AS (from the prevalent population to how they
are then sequentially treated according to their probable
symptomatic profile and surgical risk status) was thenAge-specific prevalence of severe AS
As our next step, we applied a point prevalence of 3.5%
for severe AS among individuals in the UK aged ≥75 years.
This represents a small increase in the age-­specific prevalence rate applied in the original flowchart published by
Durko and colleagues16 to reflect contemporary reportsof an increasing incidence of AS in the UK.19 Unlike theoriginal reports, we also focused on the likely burden of
severe AS among those aged 55–74 years. To derive valid
and accurate prevalence estimates for these age groups,
we analysed the pattern of severe AS within the large andunselected NEDA cohort (one of the largest ever studiesof all forms of AS to date).5 6 Using this cohort, we firstvalidated an overall prevalence estimate of 3.5% severe
AS among those aged 75 years and above as a conservative starting point for our analyses. We also noted theabsence of any major sex-­
specific differences in thisregard (concurring with the UK-­
based data from theOxVALVE Study3). Using this age group (≥75 years) as
a fixed reference point, we then used the observed age
profile of severe AS cases below the age of 75 years within

2

Strange GA, et al. Open Heart 2022;9:e001783. doi:10.1136/openhrt-2021-001783

Open Heart: first published as 10.1136/openhrt-2021-001783 on 26 January 2022. Downloaded from http://openheart.bmj.com/ on September 22, 2024 by guest. Protected by copyright.

Open HeartFigure 1 Summary model used to derive treatable burden of disease for severe aortic stenosis (AS) in the UK. To generate
our estimates, we first identified the number of individuals aged ≥55 years within the UK population (ie, those most at risk ofdeveloping severe AS) and then applied age-­specific prevalence rates to this population to determine the total number of caseswith severe AS (regardless of their symptomatic or surgical risk status) ❶. These cases were then divided into those most likely
to be asymptomatic ❷ or symptomatic ❸. Based on the assumption that symptomatic cases would most likely be detected
and, according to current guidelines,2 be most likely to be considered for treatment, this ‘symptomatic severe AS’ group
was then divided into those who might be initially considered for medical ❹ versus surgical management ❺. The former was
divided into those who would continue to receive conservative medical management ❻ versus those who might benefit fromthe increasingly accessible option of transcatheter aortic valve implantation (TAVI) ❼. The initially identified surgical cases werethen divided according to their surgical risk profile ❽ with further stratification of this subgroup according to what proportion ofhigh-­risk surgical/surgical aortic valve replacement (SAVR) cases might benefit from TAVI ❾ and, similarly, what proportion oflow-­to-­medium risk individuals being considered for SAVR might undergo TAVI instead ❿. For each estimate point from 2 to 10,
the equivalent proportion (and 95% CI) applied in the original flowchart was applied.15

the NEDA cohort to derive the following age-­
specificprevalence estimates of severe AS to be applied to the
UK population in the following age bands: aged ≥75 years(3.5%—index prevalence estimate), 70–74 years (1.2%),
65–69 years (0.7%), 60–64 years (0.5%) and 55–59 years(0.4%). This age-­specific approach differs from the original reports where population estimates (European andNorth America) were also used as a starting point, but
a single, rather than age-­stratified, point-­prevalence estimate for severe AS was applied. Critically, when theseage-­stratified estimates were applied to the UK population aged ≥55 years, they generated an overall point
prevalence of severe AS that was congruent to that of theestimated prevalence of undetected AS cases within the
OxVALVE Study cohort.3

and 95% CIs for these estimates16) according to theirlikely suitability for more conservative medical versus
surgical treatment and the subsequent option of SAVR
versus TAVI (see also figure 1). Specifically, as per theoriginal flowchart/modelling, we distributed SAVR and
TAVI treatment according to the likely perioperativerisk profile of potentially treated cases according to theSociety of Thoracic Surgeon’s Predicted Risk of Mortality
Score (STS-­PROM).20 In the absence of more specific
UK data,21 it is explicitly acknowledged that the distribution of cases according to their surgical risk and optionsfor SAVR versus TAVI will potentially underestimate oroverestimate the risk profile of cases and the numberof procedures that might be applied both now and theimmediate future.

Treatable cases
Having estimated the total number of individuals
aged ≥55 years living in the UK with severe AS, we applied
the same proportions and 95% CI developed (derived
from meta-­analyses of the published literature) and thenapplied by Durko and colleagues16 to determine what
proportion of prevalent cases would be symptomatic
versus non-­symptomatic (this latter group being lesslikely to be detected and treated) (see figure 1). Of thoseconsidered to be symptomatic, we further stratified suchindividuals (once again using the original proportions

5-year mortality
To provide an indicative estimation of the potential
number of deaths linked to severe AS without proactive
treatment in the UK based on the estimated total numberof cases living with the condition in 2019, we applied
actual 5-­year mortality rates observed within the same agegroups of the NEDA cohort who did not undergo AVR.6
Specifically, we assumed during the period 2019–2024,
17.0%, 37.5%, 43.7%, 49.1%, 58.6%, 69.2% and 83.7%of those individuals aged 55–59, 60–64, 65–69, 70–74,

Strange GA, et al. Open Heart 2022;9:e001783. doi:10.1136/openhrt-2021-001783

3Open Heart: first published as 10.1136/openhrt-2021-001783 on 26 January 2022. Downloaded from http://openheart.bmj.com/ on September 22, 2024 by guest. Protected by copyright.

Valvular heart diseaseFigure 2 Estimated point prevalence of severe (symptomatic) aortic stenosis (AS) in the UK (2019). This figure shows theestimated prevalence of severe AS across the UK in those aged ≥55 years when applying age-­specific prevalence rates (toppanel—overall prevalence of 1.48% as per purple box) in addition to those with symptoms (symptomatic rate with 95% CI
shown in dark blue box—bottom panel). All numbers are subject to rounding from the Office of National Statistics data

75–79, 80–84 and ≥85 years, respectively, with severe AS(regardless of symptomatic status) would die of any cause.
Statistical analyses
All data are presented in descriptive form with 95% CI
provided for the main estimates.
Patient and public involvement
Given the retrospective nature of study analyses, noparticipants were asked to advise on interpretation or
writing of the manuscript.
RESULTS
Prevalence of severe AS (2019)
The overall estimated point prevalence of severe AS within the
UK population aged 55 years and above in 2019 is 1.48%.
As shown in figure 2 (top panel), this currently equatesto around 300 000 UK men and women living with thispotentially deadly condition at any one time. Of these,
we estimate that just less than 200 000 people will present
with symptomatic, severe AS (figure 2, bottom panel).
The remainder of cases who remain asymptomatic (92 389(95% CI ~70 000 to ~144 000) people) are unlikely to be4

detected/diagnosed unless subject to proactive screening
for AS or undergoing investigation for another cardiac
condition.
Treatment of severe symptomatic AS (2019)
Overall, we estimate that 82 809 out of 199 059 symptomatic individuals (95% CI ~74 000 to ~92 000) initiallyconsidered unsuitable for surgery would be treated withmedical management. Of these cases, 51 093 individuals(95% CI ~35 000 to~68 000) might be eligible for/benefit
from TAVI. Among the remainder of symptomatic cases,
we estimate that 116 251 (95% CI ~107 000 to ~126 000)
individuals could be immediately considered for surgicalintervention. As shown in figure 3 (distribution of SAVR
procedures) figure 4 (distribution of TAVI procedures),based on the projected surgical risk profile of these 199059 prevalent cases with symptomatic severe AS and thehistorical distribution of procedures used to treat them,around 116 000 and 51 000 SAVR and TAVI procedures
respectively, would be therapeutically indicated.
5-year mortality among all prevalent cases
Depending on the type of treatment applied, it is estimated that up to 172 859 of the 291 448 prevalent cases
Strange GA, et al. Open Heart 2022;9:e001783. doi:10.1136/openhrt-2021-001783

Open Heart: first published as 10.1136/openhrt-2021-001783 on 26 January 2022. Downloaded from http://openheart.bmj.com/ on September 22, 2024 by guest. Protected by copyright.

Open HeartFigure 3 Estimated cases of severe, symptomatic aortic stenosis (AS) in the UK considered for surgical aortic valve
replacement (SAVR) (2019). This figure shows the estimated number (with 95% CI) of prevalent cases of symptomatic, severe
AS aged ≥55 years who would be considered for SAVR according to their STS-­PROM risk category (rates provided in blackboxes).

Overall burden and indicative management of severe AS
Figure 5 presents the overall, prevalent burden of severe
AS in the UK for the year 2019 among those individuals aged ≥55 years. Based on their likely symptomatic/
diagnosed status, it also shows the indicative therapeutic
application of AVR according to the strata of estimates
described above. In summary, of close to 200 000 people
aged years and over in the UK estimated to be living withsymptomatic, severe AS, around 168 000 would potentially benefit from an AVR. Of such individuals, close to
70 000 will be aged <75 years and therefore at high risk ofpremature mortality without proactive treatment. Additionally, just over 92 000 people will be living with severe
AS but without symptoms representing a largely unknown
quantity in terms of treatment status.

DISCUSSION
To our knowledge, this is the first study to specificallyestimate the treatable burden of disease associatedwith severe, symptomatic AS within the UK population. Largely driven by an ageing post-­war population
cohort, we estimate that close to 300 000 adults are
currently living with this potentially deadly condition
at any one time. Of these, around two-­thirds would
potentially qualify for SAVR or TAVI based on current
guidelines.2 22 Critically, such an indicative burden is
far greater than the current capacity within the NHS toscreen, detect, triage and treat such cases.12 Moreover,consistent with the prediction of a more than doublingin valvular cases in the UK by 2046 (on the way to a
total of 3.3 million prevalent cases in 20563), based onthese prevalence and survival estimates and new datafrom the NEDA cohort,5 we further estimate that theannual number of new cases of severe AS among those
aged ≥60 years is close to 29 000. Applying the same
surgical risk profile as before, around 20 000 people
would potentially benefit from SAVR or TAVI.
AS is the most common acquired heart valve diseaserequiring active clinical intervention.1 2 Its development
is typically gradual and can go undetected without active
case ascertainment.23 24 Moreover, the natural history of
AS is unpredictable, although the prognosis of severe

Strange GA, et al. Open Heart 2022;9:e001783. doi:10.1136/openhrt-2021-001783

5of severe AS (59.3% overall) will potentially die during
the period 2019–2024 (an annual rate of ~35 000 severeAS-­related deaths per annum). Reflective of their lower
numbers and more favourable survival rates, we estimatethat 9807 deaths (5.7% of all deaths) will occur in thoseinitially aged 55–64 years with an additional 29 548 deaths(17.1%) occurring in those aged 65–74 years. Accordingly, most deaths will occur in those aged 75–84 years(86 383 deaths—50.0%) and ≥85 years (47 121 deaths—
27.3%).

Open Heart: first published as 10.1136/openhrt-2021-001783 on 26 January 2022. Downloaded from http://openheart.bmj.com/ on September 22, 2024 by guest. Protected by copyright.

Valvular heart diseaseFigure 4 Estimated cases of severe, symptomatic aortic stenosis (AS) in the UK considered for transcatheter aortic valve
implantation (TAVI) (2019). This figure shows the estimated number (with 95% CI) of prevalent cases aged ≥55 years who would
be considered too high risk for surgical aortic valve replacement (SAVR) but instead be potential candidates for TAVI (sequential
estimate rates for both provided in the red boxes).

AS, especially once associated with symptoms, is often
worse than most cancers.1 The potential value of early
detection of AS and guideline driven interventional

treatment in severe AS is substantial, given the evidence
that such procedures prolong life.2 11 However, realising
this life-­saving potential requires an understanding of

Figure 5 Summary of the estimated (prevalent) burden and management of severe aortic stenosis (AS) in the UK (2019).
SAVR, surgical aortic valve replacement; TAVI, transcatheter aortic valve implantation.

6

Strange GA, et al. Open Heart 2022;9:e001783. doi:10.1136/openhrt-2021-001783

Open Heart: first published as 10.1136/openhrt-2021-001783 on 26 January 2022. Downloaded from http://openheart.bmj.com/ on September 22, 2024 by guest. Protected by copyright.

Open Heartthe true size of the population with severe AS who would
benefit from treatment and the resources required tomeet their therapeutic needs. Building on a previously
published model15 with specific adjustments derived
from NEDA6, we applied a robust set of estimates todetermine the treatable burden of severe AS within the
UK population. Beyond establishing the existence of alarge prevalent population of severe AS (around 300 000
people), we further estimate that around 28 000 will
newly develop this condition each year. To place thesefigures into a clinical capacity/health service context,
in the year 2018–2019 the following procedures werereported to the national audits: 5197 TAVI, 5091
isolated SAVR and 2739 combined SAVR combinedwith coronary artery bypass grafting (a total of 13 027
procedures).25 The surgical figures include those from
Ireland, and some surgical procedures will have been
undertaken for aortic regurgitation rather than AS but
making some allowance for this it would be reasonable
to suggest that around 10 000 procedures were undertaken in the UK that year for severe AS, representing
around 50% of the total we have projected to be developing symptomatic severe AS each year, and therefore
being potential candidates for surgical or transcatheter
intervention. There seems little doubt therefore that
there is a significant shortfall between interventions
undertaken for severe AS and our estimates of potential demand. Critically, our estimates of the treatableburden of AS are consistent with the limited datareported previously15 16 and our overall prevalence estimate of 1.48% is congruent with the 1.3% prevalence of
undetected AS in the OxVALVE Study.3 However, evena small difference between the estimated prevalence(1.48% when combining all-­age-­specific rates applied)versus actual prevalence of severe AS in the UK will
increase the magnitude of error across our projections.
Given the substantial cost of treating AS, such uncertainty reinforces the need for contemporary studies ofthe population and clinical epidemiology of this potentially deadly and disabling condition.2
The NHS Long Term Plan (2019) highlighted
the need for better detection of heart valve disease
and access to specialist care for these patients.12 The
current study provides estimates for the burden of
severe AS, and the likely number of SAVR and TAVI
procedures that will be needed to treat this populationin an optimal time frame, so that commissioners, andother professionals delivering care, can plan services
appropriately. Specifically, the estimated demand willassist the planning of screening processes in primarycare (noting the more than 90 000 cases estimated to
be asymptomatic), and quicker access to secondary
care assessment, and receive AVR where appropriate.
The requirements for expansion of current facilities,
improved training of staff and increased staff numbers
will be much easier to estimate based on the modelling produced by this and other research. It will also
allow for service improvements that are consistent with
Strange GA, et al. Open Heart 2022;9:e001783. doi:10.1136/openhrt-2021-001783

national standards and guidelines, such as those soon
to be published by the National Institute for Health &Care Excellence (NICE) and the Getting it Right FirstTime programme. Recent data from the UK reveals
concerning trends with regard to the inequitable accessto TAVI, under provision of TAVI for severe symptomatic AS patients, and high rates of mortality for patientson TAVI waiting lists.13 Further, recent data from the UK
NICOR dataset highlight the detrimental effect of the
COVID-­19 pandemic on provision of both SAVR and
TAVI for existing patients with AS.21 Such data highlight the need for a robust and equitable plan to deliver
potentially life-­saving services to a growing number ofpeople in the UK already affected, or soon to be, by
severe AS.

LIMITATIONS
It is important to note that beyond largely reliable
population statistics (the dynamics of which are mostimportant in driving burden of disease estimates), we
currently have no means to verify if our overlaying
estimates of the prevalence/incidence and treatableburden of disease are correct. Where possible, we havesought to corroborate these vital statistics via the large
NEDA cohort.5 6 We also applied the 95% CI aroundthe key estimates that were synthesised by Durko andcolleagues via meta-­analyses and Monte Carlo simulations of data from a broad range of countries. However,as noted in the current ESC/EACTS guidelines, STS-­PROM Scores are inherently variable, and these will
influence treatment options.2
Notably, beyond a population-­based report from theTromsø Study,26 the underlying prevalence and incidenceof AS at the whole population level remains poorly characterised. Thus, all our estimates should be cautiouslyinterpreted.

SUMMARY
In conclusion, this study suggests that severe AS is acommon condition affecting many individuals within
the UK population aged ≥55 years. Without appropriate
detection and intervention, their survival prospects
are likely to be poor. However, the indicative treatableburden of disease (around 20 000 new, potentially treatable cases each year) is discordant with current capacity
within the NHS to deliver AVRs in the form of SAVR
or TAVI (regardless of the ratio in which these twodifferent procedures might be applied).
Author affiliations
1
School of Medicine, University of Notre Dame, Freemantle, Western Australia,
Australia
2
Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales,
Australia
3
Centre for Cardiopulmonary Health, Torrens University Australia, Adelaide, South
Australia, Australia
4
School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK

7Open Heart: first published as 10.1136/openhrt-2021-001783 on 26 January 2022. Downloaded from http://openheart.bmj.com/ on September 22, 2024 by guest. Protected by copyright.

Valvular heart disease5Consultant Cardiologist, Faculty of Medicine, University of Southampton & Wessex
Cardiothoracic Unit, University Hospital Southampton NHS Trust, Southampton, UK
6Consultant Cardiologist, Manchester University Hospitals Foundation Trust,
Manchester, UK
7
President, Society of Cardiothoracic Surgeons of Great Britain & Ireland, UK
8Consultant Cardiothoracic Surgeon, Sheffield Teaching Hospitals NHS Foundation
Trust, Sheffield, UK
9Consultant Cardiac Scientist, Manchester University NHS Foundation Trust,
Manchester, UK
10Consultant Cardiac Surgeon, Royal Infirmary, Edinburgh, UK
11
Emeritus National Clinical Director for Heart Disease, NHS England, UK
Contributors GS, SS and HHG conceived the study. SS designed and performed
the data analysis. GS, SS and HHG wrote the manuscript.GS, SS, NC, SR, SK, PB,
KP, RP, DP and HHG interpreted the data and made substantial contributions to therevision and have approved the submitted version. GS accepts full resonsibility
for the finished work and/or conduct of the study, had access to the data, andcontrolled the decision to publish.
Funding The authors have not declared a specific grant for this research from any
funding agency in the public, commercial or not-­for-­profit sectors.
Map disclaimer The inclusion of any map (including the depiction of any
boundaries therein), or of any geographic or locational reference, does not imply
the expression of any opinion whatsoever on the part of BMJ concerning the legal
status of any country, territory, jurisdiction or area or of its authorities. Any such
expression remains solely that of the relevant source and is not endorsed by BMJ.
Maps are provided without any warranty of any kind, either express or implied.
Competing interests GS: Research grants: Actelion, Bayer, Edwards, GSK, Jensen,
Novartis. Consultancies: Edwards, Echo IQ, NEDA Ltd. SS: Research grants: Actelion,
Bayer, Edwards, GSK, Jensen, Novartis. NC: Research grants: Boston Scientific,
HeartFlow, Beckmann Coulter. Speaker Fees/Consultancy: HeartFlow, Abbott,
Edwards. Travel Sponsorship: HeartFlow, Boston Scientific, Biosensors, Medtronic,
Edwards. PB: Honoraria: Edwards Lifesciences and Atricure Ltd. DP: Research
grants: Actelion, Bayer, Edwards, GSK, Jensen, Novartis. HHG: Consultancies:
Wilmington Healthcare, Edwards Lifesciences, Heart Valve Voice.
Patient consent for publication Not applicable.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement All data relevant to the study are included in thearticle or uploaded as supplementary information.
Open access This is an open access article distributed in accordance with theCreative Commons Attribution Non Commercial (CC BY-­NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work non-­commercially,and license their derivative works on different terms, provided the original work is
properly cited, appropriate credit is given, any changes made indicated, and the use
is non-­commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
ORCID iDs
Geoffrey A Strange http://orcid.org/0000-0001-6800-7119
Simon Stewart http://orcid.org/0000-0001-9032-8998
Nick Curzen http://orcid.org/0000-0001-9651-7829
Simon Ray http://orcid.org/0000-0001-7775-1900
David Playford http://orcid.org/0000-0003-4492-1103

REFERENCES

1 Nkomo VT, Gardin JM, Skelton TN, et al. Burden of valvular heartdiseases: a population-­based study. Lancet 2006;368:1005–11.
2 Beyersdorf F, Praz F, Milojevic M. 2021 ESC/EACTS guidelines forthe management of valvular heart disease. Eur Heart J 2021;00:1–72.
3 d'Arcy JL, Coffey S, Loudon MA, et al. Large-­scale community
echocardiographic screening reveals a major burden of undiagnosed
valvular heart disease in older people: the OxVALVE population
cohort study. Eur Heart J 2016;37:3515–22.

8

4 Nchimi A, Dibato JE, Davin L, et al. Predicting disease progression
and mortality in aortic stenosis: a systematic review of imaging
biomarkers and meta-­analysis. Front. Cardiovasc. Med. 2018;5:112.
5 Stewart S, Chan Y-­K, Playford D, et al. Incident aortic stenosis
in 49 449 men and 42 229 women investigated with routine
echocardiography. Heart 2021;8:heartjnl-­2021-­319697.
6 Strange G, Stewart S, Celermajer D, et al. Poor long-­term survival
in patients with moderate aortic stenosis. J Am Coll Cardiol
2019;74:1851–63.
7 Strange G, Scalia GM, Playford D, et al. Uncovering the treatableburden of severe aortic stenosis in Australia: current and future
projections within an ageing population. BMC Health Serv Res
2021;21:790.
8 Frey N, Steeds RP, Rudolph TK, et al. Symptoms, disease severity
and treatment of adults with a new diagnosis of severe aortic
stenosis. Heart 2019;105:1709–16.
9 Lancellotti P, Magne J, Dulgheru R, et al. Outcomes of patients withasymptomatic aortic stenosis followed up in heart valve clinics.
JAMA Cardiol 2018;3:1060–8.
10 San Román JA, Vilacosta I, Antunes MJ, et al. The ‘wait for
symptoms’ strategy in asymptomatic severe aortic stenosis. Heart
2020;106:1792–7.
11 Playford D, Stewart S, Celermajer D, et al. Poor survival with
impaired valvular hemodynamics after aortic valve replacement: the
National echo database Australia study. J Am Soc Echocardiogr
2020;33:1077–86.
12 National Health Service, 2021. Available: https://www.longtermplan.​
nhs.uk [Accessed May 2021].
13 Ali N, Faour A, Rawlins J, et al. 'Valve for life': tackling the deficit intranscatheter treatment of heart valve disease in the UK. Open Heart
2021;8.
14 Chambers JB. Aortic stenosis: service delivery before guidelines.
Heart 2019;105:1686–7.
15 Osnabrugge RLJ, Mylotte D, Head SJ, et al. Aortic stenosis in
the elderly: disease prevalence and number of candidates fortranscatheter aortic valve replacement: a meta-­analysis andmodeling study. J Am Coll Cardiol 2013;62:1002–12.
16 Durko AP, Osnabrugge RL, Van Mieghem NM, et al. Annual
number of candidates for transcatheter aortic valve implantation
per country: current estimates and future projections. Eur Heart J
2018;39:2635–42.
17 Stewart S, MacIntyre K, Capewell S. Heart failure and the aging
population: an increasing burden in the 21st century? Heart
2003;89:49–53.
18 Population estimates for the UK, England and Wales, Scotland andNorthern Ireland - Office for National Statistics (​ons.​gov.​uk).
19 Nazarzadeh M, Pinho-­Gomes A-­C, Bidel Z, et al. Plasma lipids andrisk of aortic valve stenosis: a Mendelian randomization study. Eur
Heart J 2020;41:3913–20.
20 Serruys PW, Modolo R, Reardon M, et al. One-­Year outcomes ofpatients with severe aortic stenosis and an STS PROM of less than
three percent in the SURTAVI trial. EuroIntervention 2018;14:877–83.
21 Martin GP, Curzen N, Goodwin AT, et al. Indirect impact of the
COVID-­19 pandemic on activity and outcomes of transcatheterand surgical treatment of aortic stenosis in England. Circulation
2021;14:e010413.
22 Otto CM, Baumgartner H. Updated 2017 European and American
guidelines for prosthesis type and implantation mode in severe aortic
stenosis. Heart 2018;104:710–3.
23 Rosenhek Ret al. Mild and moderate aortic stenosis natural
history and risk stratification by echocardiography. Eur Heart J
2004;25:199–205.
24 Delesalle G, Bohbot Y, Rusinaru D, et al. Characteristics andprognosis of patients with moderate aortic stenosis and preserved
left ventricular ejection fraction. J Am Heart Assoc 2019;8:e011036.
25 Adult Cardiac Surgery (Surgery Audit). National Institute for
cardiovascular outcomes research (NICOR). Available: https://www.nicor.org.uk/national-cardiac-audit-programme/adult-cardiac-​
surgery-surgery-audit/ [Accessed Jun 2021].
26 Eveborn GW, Schirmer H, Heggelund G, et al. Incidence of aortic
stenosis in subjects with normal and slightly elevated aortic
gradients and flow. Heart 2015;101:1895–900.

Strange GA, et al. Open Heart 2022;9:e001783. doi:10.1136/openhrt-2021-001783

Open Heart: first published as 10.1136/openhrt-2021-001783 on 26 January 2022. Downloaded from http://openheart.bmj.com/ on September 22, 2024 by guest. Protected by copyright.

Open Heart