The decision-making of treatment and outcome in elderly patients with symptomatic severe aortic stenosis
Authors: Zhao Q , Xu H , Lv J , Wu Y 
Published: November 2020

Abstract

Background
The prevalence of aortic stenosis (AS) steadily increases with age. There is a consensus that intervention should be advised in patients with symptomatic severe AS. However, decision to operate raises complex issues in the elderly due to the increasing operative comorbidity and mortality. There is limited information regarding the characteristics and outcome of elderly patients with symptomatic severe AS who were denied intervention and the reasons leading to the denial.

Purpose
To analyze the decision-making and the prognosis in elderly patients with symptomatic severe AS.

Methods
In a cohort of 8929 patients aged ≥60 years with significant valvular heart disease, we divided patients with severe (valve area ≤1 cm2 or peak velocity ≥4.0 m/s or mean gradient ≥40 mmHg), symptomatic (angina or NYHA II-IV or syncope) AS into three groups by final treatment decision: intervention group, doctor-deny group, patient-deny group. The impact of characteristics on decision-making was evaluated and 1-year mortality among three groups were compared.

Results
Among 546 patients with severe symptomatic AS, the interventional decision was taken in 338 patients (61.9%), 134 patients (24.5%) were denied intervention by doctor after evaluation and 74 patients (13.5%) refused intervention due to personal preference. In multivariable analysis, age [OR=1.104, 95% CI (1.068–1.142)], multi-comorbidities [OR=4.706, 95% CI (2.355–9.403)] and left ventricular end-diastolic diameter (LVEDD) [OR=1.021, 95% CI (1.001–1.042)] were markedly associated with the conservative decision made by doctor, while LVEF &gt;50% [OR=0.260, 95% CI (0.082–0.823)] was significantly linked with the interventional decision. Lower mortality was observed in intervention group during 1-year follow-up compared with either doctor-deny group or patient-deny group (both P&lt;0.001 after adjustment). Further, diabetes [HR=2.513, 95% CI (1.243–5.084)], syncope [HR=2.856, 95% CI (1.338–6.098)], atrial fibrillation (AF) [HR=2.764, 95% CI (1.305–5.855)], stroke [HR=2.921, 95% CI (1.252–6.851)] and multi-comorbidities [HR=3.120, 95% CI (1.363–7.142)] were strong 1-year mortality predictors, whereas interventional treatment [HR=0.195, 95% CI (0.091–0.417)] and LEVF &gt;50% [HR=0.960, 95% CI (0.938–0.984)] were related to lower mortality.

Conclusions
Intervention was denied in about forty percent of elderly patients with symptomatic severe AS. Patients with advanced age, multi-comorbidities and increased LVEDD tended to be denied intervention by doctors, whereas interventions were more likely to be performed on patients with normal LVEF. Diabetes, syncope, AF, stroke and multi-comorbidities were the predictive factors of 1-year mortality. Elderly patients with symptomatic severe AS could benefit from intervention. Patient education needs to be strengthened, to encourage more patients accept the appropriate intervention.

Funding Acknowledgement
Type of funding source: Public grant(s) – National budget only. Main funding source(s): National Twelfth Five-year Science and Technology Support Projects by Ministry of Science and Technology of China