Treatment Patterns, Disparities, and Management Strategies Impact Clinical Outcomes in Patients with Symptomatic Severe Aortic Regurgitation

ABSTRACT

Background

Symptomatic severe aortic regurgitation (ssAR) is a Class I recommendation for surgical aortic valve replacement (SAVR). We sought to evaluate the practice patterns and drivers of ssAR patients receiving SAVR treatment.

Methods

Using a US dataset of de-identified electronic health records, we identified integrated delivery network patients diagnosed with ssAR between 2008 and 2016 with ≥2 symptom-related notes (heart failure, angina, dyspnea, pre-syncope, or syncope) within six months prior to diagnosis.

Results

From a final cohort of 4,608 ssAR patients, 25.7% of ssAR patients underwent SAVR within 1 year of diagnosis; mortality at 1 year was 9% after SAVR, and 24% for those untreated. Using multilevel, multivariable, cause-specific models, women and patients >80 years old were found to be treated significantly less likely [hazard ratios (HR) 0.79 (95% confidence interval [CI]: 0.69–0.90) and 0.28 (0.22–0.37), respectively]. Patients with concomitant moderate/severe aortic stenosis [1.70 (1.43–2.03)], bicuspid aortic valve disease [1.33 (1.13–1.56)], and endocarditis [2.70 (1.04–3.57)] were more likely to be treated. Using multivariable Cox proportional hazard models, ssAR patients managed by cardiologists in the highest SAVR treatment rate tertile had a 23% lower risk of 1-year mortality compared to patients managed by cardiologists in the lowest SAVR treatment rate tertile [0.77 (0.60–0.98)].

Conclusions

We identified significant disparities in the treatment of ssAR patients, specifically women, older patients, and patients managed by cardiologists with a lower SAVR treatment rate. These gaps should be addressed to level the quality of care delivered to all ssAR patients.

KEYWORDS:

• Aortic regurgitation
• surgical aortic valve replacement
• SAVR

Supplementary material

Supplemental data for this article can be accessed on the publisher’s website

Disclosure statement

Dr. Thourani has received research grants from Abbott Medical and Medtronic, and consultant fees from Boston Scientific, Edwards Lifesciences, and JenaValve. Dr. Brennan, Ms. Chen, and Dr. Boero have received consultant fees from Edwards Lifesciences. Ms. Murphy is an employee of Edwards Lifesciences. Dr. Leon receives consulting fees from Abbott Medical, Boston Scientific, and Medtronic, has ownership interest in Claret, and research grants from Edwards Lifesciences. Dr. Kodali has received consulting fees from Admedus, Meril Lifesciences, JenaValve, and Abbott Medical; research funding from Edwards Lifesciences, Medtronic, Abbott Vascular, Boston Scientific, JenaValve; and has scientific advisory board positions from Dura Biotech, MicroInterventional Devices, Thubrikar Aortic Valve, Supira, and Admedus. Drs. Edelman and Sarkar have nothing to disclose.

Additional information

Funding

This research was funded by Edwards Lifesciences, but the Investigators were not remunerated. Edwards was involved only in the review and revision of this manuscript.