Association of Guideline Adherence for Serial Evaluations With Survival and Adverse Clinical Events in Patients With Asymptomatic Severe Aortic Stenosis

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Abstract

Importance

For patients with asymptomatic severe aortic stenosis and normal left ventricular function, current practice guidelines empirically recommend serial evaluations every 6 to 12 months. The benefit of this clinical monitoring is unknown.

Objective

To determine the association of guideline adherence with clinical outcomes in patients with asymptomatic severe aortic stenosis.

Design, Setting, and Participants

This retrospective cohort study involved 300 patients with asymptomatic severe aortic stenosis who were seen in the ambulatory Minneapolis Heart Institute at Abbott Northwestern Hospital. Rates of survival and adverse clinical events, including myocardial infarction, stroke, and heart failure hospitalization, were compared between patients who adhered to serial evaluation guidance and those who did not. Medical records were reviewed from July 25, 2007, to December 6, 2012. Data analysis took place from February 4, 2017, to July 10, 2017.

Main Outcomes and Measures

All-cause mortality, heart failure hospitalization, and major adverse clinical events during follow-up.

Results

The study population of 300 comprised 143 men (47.7%) and had a mean (SD) age of 78.6 (11.5) years. There were no differences in age, race/ethnicity, sex, comorbidities, insurance status, left ventricular function, and aortic stenosis severity between patients with (n = 202) and patients without (n = 98) guideline adherence. Aortic valve replacement (surgical or catheter based) was performed more frequently (54.0% vs 19.4%; P < .001) and the median (interquartile range) time for this performance was earlier (2.2 [1.2-3.6] years vs 3.5 [2.0-5.8] years; P < .001) in patients with guideline adherence. All-cause mortality was higher for nonadherent patients (hazard ratio [HR], 1.57; 95% CI, 1.07-2.30; P < .001), and these patients also had a higher rate of hospital admission for heart failure decompensation in follow-up (HR, 1.66; 95% CI, 1.27-2.18; P < .001). Four-year survival that is free from death and heart failure hospitalization was higher for adherent patients than for nonadherent patients (38.7% vs 23.3%; P < .001), and this difference remained significant in models adjusted for baseline variables (adjusted HR, 1.54; 95% CI, 1.04-2.29; P = .03).

Conclusions and Relevance

The findings of this study support the need for close monitoring of patients with asymptomatic severe aortic stenosis and help to validate current guidelines for serial evaluations. These findings also support initiatives to improve guideline adherence in clinical practice.

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