Symptoms development overtime according to the imaging based cardiac damage staging classification in asymptomatic patients with moderate to severe aortic stenosis
Authors: Gil Fernandez J , Rojas Lavado G , Candela Ferre J , Gonzalez-Bartol E , Aristizabal-Duque C , Gomez-Salvador I , Sevilla Ruiz T , San Roman JA 
Published: February 2022

Abstract

Funding Acknowledgements
Type of funding sources: None.

Background
Recently, a new staging of patients with asymptomatic moderate to severe aortic stenosis (AS) based on extra-aortic valve cardiac damage has been described to stratify the prognostic of both, asymptomatic and symptomatic patients.

Purpose
To test the ability of this imaging based staging system to predict the development of symptoms in patients with moderate to severe asymptomatic AS.

Methods
We analyzed a retrospective cohort of 96 patients with at least moderate AS who were systematically studied with echocardiography and cardiac magnetic resonance imaging. Patients were classified according to the staging classification of extra-aortic valve damage: no cardiac damage (Stage 0), left ventricular (LV) damage: LV mass index &gt;95 g/m2 in women and &gt;115 g/m2 in men and or E/E´ratio &gt;14 and/or LV ejection fraction &lt;50% (Stage 1), mitral valve or left atrial (LA) damage: LA volume &gt;34 ml/m2, and/or atrial fibrillation and/or ≥ moderate mitral regurgitation (Stage 2), tricuspid valve or pulmonary vasculature damage: systolic pulmonary arterial pressure ≥60 mm Hg and/or moderate or greater tricuspid regurgitation (Stage 3), right ventricular damage: tricuspid annulus systolic velocity S´&lt; 9.5 cm/s, TAPSE &lt; 17 mm, and/or RV ejection fraction &lt; 50% (Stage 4). Given the small number of patients in Stages 3 and 4, patients were merged together in a single group. The primary endpoint was the development of symptoms during a follow-up of 5 years, regardless of whether the patient underwent aortic valve replacement. Kaplan-Meier curves and log-rank test of the time to development of symptoms data were used.

Results
At baseline patients had a mean age of 70.9 years old and 71.9% were male. Most of patients had hypertension (70.8%) and dyslipidemia (55.2%). 20.8% had diabetes mellitus and only 10.4% had previous coronary artery disease. The mean transvalvular gradient was 39 ± 14 mmHg and the mean aortic valve area was 1.04 ± 0.24 cm2. According to the staging scheme, 37 patients were classified in Stage 0 (38.5%), 32 in Stage 1 (33.3%), 23 in Stage 2 (24%) and 4 in the group of Stage 3-4 (4.2%). During 5 years of follow-up, 44 patients developed symptoms (33 dyspnea, 18 angina and 5 syncope), up to 40% of patients underwent aortic valve replacement and 20 patients died (20.8%), 7 of them due to cardiovascular causes. According to the staging scheme, the proportion of patients who remained asymptomatic at 5 years were: 50.3% in Stage 0, 45.8% in Stage 1, 27.3% in Stage 2, 0% in Stage 3-4 (p = 0.002). Every patient in stages 3 and 4 had developed symptoms by the third year while most patients in stage 0 remained asymptomatic within the first two years (figure 1).

Conclusions
Up to 45% of asymptomatic patients with moderate to severe AS will develop symptoms within a 5-year period. Symptoms are developed significantly earlier with incremental staging. This classification may be useful to identify patients that deserve a closer follow-up. Abstract Figure. Baseline Characteristics Abstract Figure. Symptoms development