title: Severe aortic stenosis in a veteran population: treatment considerations and survival.
abstract: BACKGROUND
  We examined factors affecting the choice of surgical versus medical treatment of severe aortic stenosis and evaluated associated patient survival.
  
  
  METHODS
  We retrospectively reviewed data from all patients diagnosed with severe aortic stenosis at a Veterans Affairs medical facility between January 1997 and April 2008.
  
  
  RESULTS
  Of 345 patients with severe aortic stenosis, 260 (75%) underwent surgical evaluation, and 205 (59%) underwent aortic valve replacement (AVR). The patient's decision to decline surgical referral or AVR (n = 47) and severe comorbidities (n = 34) were the top two reasons for medical treatment rather than AVR. The AVR group was younger (69.5 +/- 9.6 years versus 75.7 +/- 8.6 years; p < 0.001) and had a higher prevalence of symptoms (96% versus 71%; p < 0.001) than the medical group. The medical group had a lower cardiac ejection fraction (0.42 +/- 0.15 versus 0.50 +/- 0.12; p < 0.001) and was less likely to be independent in activities of daily living (64% versus 74%). The AVR group had higher survival rates than the medical patients at 1 year (92% versus 65%), 3 years (85% versus 29%), and 5 years (73% versus 16%; log-rank test p < 0.0001). Valve replacement was independently associated with decreased mortality (hazard ratio, 0.17; 95% confidence interval, 0.10 to 0.27; p < 0.0001).
  
  
  CONCLUSIONS
  The management of severe aortic stenosis in veterans is sometimes limited to medical evaluation and treatment. Surgeons should be involved in the complex process of risk assessment, to select patients with severe aortic stenosis who would benefit from the survival advantage associated with AVR.
authors.affiliation: Division of Cardiothoracic Surgery, Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, Texas 77030, USA. fbakaeen@bcm.edu
authors.forename: Faisal G
authors.initials: FG
authors.lastname: Bakaeen
authors.forename: Danny
authors.initials: D
authors.lastname: Chu
authors.forename: Mark
authors.initials: M
authors.lastname: Ratcliffe
authors.forename: Raja R
authors.initials: RR
authors.lastname: Gopaldas
authors.forename: Alvin S
authors.initials: AS
authors.lastname: Blaustein
authors.forename: Raghunandan
authors.initials: R
authors.lastname: Venkat
authors.forename: Joseph
authors.initials: J
authors.lastname: Huh
authors.forename: Scott A
authors.initials: SA
authors.lastname: LeMaire
authors.forename: Joseph S
authors.initials: JS
authors.lastname: Coselli
authors.forename: Blase A
authors.initials: BA
authors.lastname: Carabello
mesh_terms: D000203:Activities of Daily Living / Q000145:classification; D000368:Aged; D000369:Aged, 80 and over; D001024:Aortic Valve Stenosis / Q000401:mortality / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation; D002303:Cardiac Output, Low / Q000401:mortality / Q000601:surgery; D002317:Cardiovascular Agents / Q000627:therapeutic use; D015897:Comorbidity; D004452:Echocardiography; D005260:Female; D006305:Health Status Indicators; D006787:Hospitals, Veterans; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000401:mortality*; D011379:Prognosis; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D018570:Risk Assessment; D015996:Survival Rate; D016312:Treatment Refusal; D014728:Veterans
chemical_list: D002317:Cardiovascular Agents