title: Different clinical outcomes in patients with asymptomatic severe aortic stenosis according to the stage classification: Does the aortic valve area matter?
abstract: BACKGROUND
  The ACC/AHA guidelines introduced a new classification of severe aortic stenosis (AS) mainly based on maximum jet velocity (Vmax) and mean pressure gradient (mPG), but not on aortic valve area (AVA). However, prognostic value of this new classification has not yet been fully evaluated.
  
  
  RESULTS
  We studied 1512 patients with asymptomatic severe AS enrolled in the CURRENT AS registry in whom surgery was not initially planned. Patients were divided into 2 groups: Group 1 (N=122) comprised patients who met the recommendation for surgery; high-gradient (HG)-AS (Vmax≥4.0m/s or mPG≥40mmHg) with ejection fraction (EF)<50%, or very HG-AS (Vmax≥5.0m/s or mPG≥60mmHg), and Group 2 (N=1390) comprised patients who did not meet this recommendation. Group 2 was further subdivided into HG-AS with preserved EF (HGpEF-AS, N=498) and low-gradient (LG)-AS, but AVA<1.0cm2(N=892). The excess risk of Group 1 relative to Group 2 for the primary outcome measure (a composite of aortic valve-related death or heart failure hospitalization) was significant (adjusted HR: 1.92, 95%CI: 1.37-2.68, P<0.001). The excess risk of HGpEF-AS relative to LG-AS for the primary outcome measure was also significant (adjusted HR: 1.45, 95%CI: 1.11-1.89, P=0.006). Among LG-AS patients, patients with reduced EF (<50%) (LGrEF-AS, N=103) had extremely high cumulative 5-year incidence of all-cause death (85.5%).
  
  
  CONCLUSIONS
  Trans-aortic valve gradient in combination with EF was a good prognostic marker in patients with asymptomatic AS. However, patients with LGrEF-AS had extremely poor prognosis when managed conservatively.
authors.affiliation: Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan.
authors.forename: Takeshi
authors.initials: T
authors.lastname: Kitai
authors.affiliation: Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan.
authors.forename: Tomohiko
authors.initials: T
authors.lastname: Taniguchi
authors.affiliation: Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan.
authors.forename: Takeshi
authors.initials: T
authors.lastname: Morimoto
authors.affiliation: Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan.
authors.forename: Toshiaki
authors.initials: T
authors.lastname: Toyota
authors.affiliation: Department of Cardiology, Tenri Hospital, Tenri, Japan.
authors.forename: Chisato
authors.initials: C
authors.lastname: Izumi
authors.affiliation: Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan.
authors.forename: Shuichiro
authors.initials: S
authors.lastname: Kaji
authors.affiliation: Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan.
authors.forename: Kitae
authors.initials: K
authors.lastname: Kim
authors.affiliation: Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan.
authors.forename: Naritatsu
authors.initials: N
authors.lastname: Saito
authors.affiliation: Department of Cardiovascular Center, Osaka Red Cross Hospital, Osaka, Japan.
authors.forename: Kazuya
authors.initials: K
authors.lastname: Nagao
authors.affiliation: Department of Cardiovascular Center, Osaka Red Cross Hospital, Osaka, Japan.
authors.forename: Tsukasa
authors.initials: T
authors.lastname: Inada
authors.affiliation: Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan.
authors.forename: Eri
authors.initials: E
authors.lastname: Minamino-Muta
authors.affiliation: Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan.
authors.forename: Takao
authors.initials: T
authors.lastname: Kato
authors.affiliation: Cardiovascular Center, The Tazuke Kofukai Medical Research Institute, Kitano Hospital, Osaka, Japan.
authors.forename: Moriaki
authors.initials: M
authors.lastname: Inoko
authors.affiliation: Department of Cardiology, Kansai Electric Power Hospital, Osaka, Japan.
authors.forename: Katsuhisa
authors.initials: K
authors.lastname: Ishii
authors.affiliation: Department of Cardiovascular Surgery, Kobe City Medical Center General Hospital, Kobe, Japan.
authors.forename: Tadaaki
authors.initials: T
authors.lastname: Koyama
authors.affiliation: Department of Cardiovascular Surgery, Kobe City Medical Center General Hospital, Kobe, Japan.
authors.forename: Ryuzo
authors.initials: R
authors.lastname: Sakata
authors.affiliation: Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan.
authors.forename: Yutaka
authors.initials: Y
authors.lastname: Furukawa
authors.affiliation: Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan. Electronic address: taketaka@kuhp.kyoto-u.ac.jp.
authors.forename: Takeshi
authors.initials: T
authors.lastname: Kimura
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001021:Aortic Valve / Q000473:pathology*; D001024:Aortic Valve Stenosis / Q000145:classification* / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D015331:Cohort Studies; D000072700:Conservative Treatment / Q000379:methods; D004452:Echocardiography; D005260:Female; D019918:Heart Valve Prosthesis Implantation / Q000379:methods; D006801:Humans; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D011237:Predictive Value of Tests; D011379:Prognosis; D016016:Proportional Hazards Models; D012042:Registries; D012189:Retrospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D012955:Societies, Medical; D013318:Stroke Volume / Q000502:physiology*; D015996:Survival Rate; D016896:Treatment Outcome
keywords: Follow-up studies; Prognosis; Surgery; Valves