Predictors of major adverse cardiovascular events in patients with severe aortic stenosis awaiting aortic valve replacement

Abstract

Abstract Background Severe aortic stenosis (AS) is a progressive disease associated with an increased risk of heart failure (HF) and mortality if left untreated. Aortic valve replacement (AVR) is the treatment of choice. However, it is not always immediately available, and some patients have experienced major cardiovascular events (MACE) while waiting for AVR. The identification of reliable predictors of MACE can help clinicians risk-stratify severe AS patients and tailor their management to prevent adverse outcomes. Purpose We aimed to evaluate predictors of MACE in real-world patients with severe AS who are waiting for AVR. Methods We conducted a prospective registry of consecutive patients discussed in the Heart Team meeting of a single centre, between January 2018 and June 2021. All patients with severe AS were included. For each patient we recorded demographic data, blood test results, echocardiogram parameters, and MACEs (a composite of death, HF hospitalization, non-fatal acute myocardial infarction, and non-fatal stroke). MACEs were recorded until the patient underwent AVR. The median follow-up time was 187 days (IQR 59-352). Results Overall, 235 patients were included (mean age 76.7±10.7 years, 48.1% male). Previous HF hospitalization (HR 2.77, 95% CI 1.66 – 4.62), HF symptoms with New York Heart Association (NHYA) class ≥3 (HR 2.64, 95% CI 1.58–4.39), and the presence of left ventricular dysfunction (HR 2.86, 95% CI 1.71–4.78) were independent predictors of MACE (Figure 1). The presence of pulmonary hypertension (HR 2.16, 95CI 1.27–3.66), but not right ventricular dysfunction (HR 2.34, 95CI 0.45–12.08, p=0.31), was associated with MACE until AVR. Concomitant moderate to severe tricuspid regurgitation (HR 10.88, 95CI 1.41–83.94) and moderate to severe mitral regurgitation (HR 5.91, 95CI 1.50–23.34) were associated with a worse prognosis, even when adjusted for other relevant MACE predictors. Laboratory data such as serum creatinine, haemoglobin, and NT-proBNP levels were not associated with the occurrence of MACE in this population (HR 1.00). Past medical history of hypertension, diabetes, chronic kidney disease, and chronic obstructive pulmonary disease were not associated with MACE. Age was a limited predictor of MACE (HR 1.03, 95CI 1.00 – 1.06, p=0.04). Conclusion Previous HF hospitalization, NYHA class ≥3 symptoms, left ventricular dysfunction, and pulmonary hypertension were independent predictors of MACE in patients with severe AS awaiting AVR. Additionally, concomitant moderate to severe tricuspid and mitral regurgitation were also associated with worse prognosis. These findings may help identify those at high risk of MACE who would benefit most from early intervention and close monitoring.