title: Predictors and progression of aortic stenosis in patients with preserved left ventricular ejection fraction.
abstract: We aimed to characterize the hemodynamic progression of aortic stenosis (AS) in a contemporary unselected cohort of patients with preserved left ventricular ejection fraction. Current guidelines recommend echocardiographic surveillance of hemodynamic progression. However, limited data exist on the expected rate of progression and whether clinical variables are associated with accelerated progression in contemporarily managed patients with AS. We conducted a retrospective analysis of patients presenting with AS and explored the trajectory of AS mean gradient over time using generalized estimating equations and fit a longitudinal linear regression model with adjustment for baseline clinical variables. A total of 1,558 patients (median age 72; interquartile range 65 to 79) having mild (n = 982), moderate (n = 363), or severe AS (n = 213) were included. In patients with mild AS at baseline (n = 983), 303 (31%) had progressed to moderate/severe AS/AVR within 5 years of the index echo. In patients with moderate AS, 159 of 363 (44%) had progressed to severe AS/AVR within 2 years of the index echo. The annual change in mean gradient was dependent on baseline AS severity. Average annual increases in mean gradient were 6.8% (95% confidence interval 6.0 to 7.6) and 7.1% (95% confidence interval 4.8 to 9.3) in patients with mild and moderate AS, respectively. In the subset of patients with mild AS at baseline, age (p = 0.0310) and gender (p = 0.0270) had significant interaction with change in mean gradient over time. In patients with moderate AS, age (p <0.0001), gender (p = 0.0346), renal dysfunction (p = 0.0036), and hyperlipidemia (p = 0.0010) demonstrated significant interaction with change in mean gradient over time. In conclusion, although average disease progression was slower than previously reported, a significant proportion of patients with mild and moderate AS progressed to higher grades within the currently recommended time windows for echocardiographic follow-up.
authors.affiliation: Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina; The Heart Center, Department of Cardiology, University of Copenhagen, Rigshospitalet, Denmark.
authors.forename: Mads
authors.initials: M
authors.lastname: Ersboll
authors.affiliation: The Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina.
authors.forename: Phillip J
authors.initials: PJ
authors.lastname: Schulte
authors.affiliation: Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina.
authors.forename: Fawaz
authors.initials: F
authors.lastname: Al Enezi
authors.affiliation: The Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina.
authors.forename: Linda
authors.initials: L
authors.lastname: Shaw
authors.affiliation: The Heart Center, Department of Cardiology, University of Copenhagen, Rigshospitalet, Denmark.
authors.forename: Lars
authors.initials: L
authors.lastname: Køber
authors.affiliation: Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina.
authors.forename: Joseph
authors.initials: J
authors.lastname: Kisslo
authors.affiliation: Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina.
authors.forename: Irfan
authors.initials: I
authors.lastname: Siddiqui
authors.affiliation: Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Piccini
authors.affiliation: Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina.
authors.forename: Donald
authors.initials: D
authors.lastname: Glower
authors.affiliation: Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina.
authors.forename: J Kevin
authors.initials: JK
authors.lastname: Harrison
authors.affiliation: Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina.
authors.forename: Thomas
authors.initials: T
authors.lastname: Bashore
authors.affiliation: Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina.
authors.forename: Niels
authors.initials: N
authors.lastname: Risum
authors.affiliation: Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina.
authors.forename: James G
authors.initials: JG
authors.lastname: Jollis
authors.affiliation: Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina; The Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina.
authors.forename: Eric J
authors.initials: EJ
authors.lastname: Velazquez
authors.affiliation: Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina. Electronic address: zainab.samad@dm.duke.edu.
authors.forename: Zainab
authors.initials: Z
authors.lastname: Samad
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001024:Aortic Valve Stenosis / Q000175:diagnosis* / Q000503:physiopathology; D018450:Disease Progression; D004452:Echocardiography; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D011446:Prospective Studies; D012720:Severity of Illness Index; D013318:Stroke Volume; D016277:Ventricular Function, Left / Q000502:physiology*