Age disparity among severe aortic stenosis patients: AVR treatment rates and clinical outcomes among octogenarians

Abstract

Abstract Introduction Aortic valve replacement (AVR) is considered one of the most effective disease-modifying procedures among patients with severe Aortic Stenosis (sAS). Accordingly, we can witness a consistent increase in procedure rates in recent years. Nevertheless, the elderly population, particularly octogenarians, remains relatively undertreated. Purpose The current study aims to document the baseline characteristics, disparities in AVR rates, and prognostic significance of AVR among octogenarian vs. non-octogenarian patients with sAS. Methods A vast database of Maccabi health services, the second largest health maintenance organization (HMO) in Israel, counting nearly 2.8 million members, was retrospectively analyzed from 2005 to 2021 for all patients over 60 years, with a detailed echocardiography report compatible with a diagnosis of sAS. Patients who underwent AVR previously or on the same day of their diagnostic echocardiography were excluded. The database was extracted using the MDClone ADAMS healthcare data platform, generating synthetic data reliably representing the original population. All-cause mortality was set to be the primary outcome, and survival models utilizing adjusted multivariable analyses for several clinical and echocardiographic parameters were applied. Results A total of 1359 patients with high-gradient sAS were included in the final analysis, of which 574 (42%) are octogenarians. The octogenarian group included more females (56% vs. 48%), and they had a significantly higher prevalence of hypertension (83% vs. 78%), atrial fibrillation (22% vs. 14%), previous myocardial infarction (12% vs. 8%) and heart failure (20% vs. 10%). Substantial differences were documented regarding AVR-treatment rates between the two groups, with the undertreatment of the octogenarian group (39% vs. 60% of AVR within 18 months from diagnosis of sAS, p<0.001). Differences remained significant in a fully adjusted time-to-event model (HR 0.54, 95% CI 0.46-0.64, p<0.001 for octogenarians) A time-dependent analysis showed that AVR was associated with reduced all-cause mortality (HR 0.30, 95% CI 0.23-0.41, p<0.001) within the octogenarian group in 5 years. A similar protective effect was shown in the non-octogenarian group (HR 0.32, 95% CI 0.22-0.46, p<0.001). Conclusions Despite having comparable survival benefits, octogenarian patients with sAS still receive lower AVR treatment rates than non-octogenarians