Aortic Stenosis in Women Tied to Greater Mortality, Less AVR Than Men

Women with aortic stenosis tend to be referred less often for aortic valve replacement and to have worse survival compared with men despite similar baseline disease severity, according to new data.

Because men tended to be diagnosed more often with aortic stenosis in the past, it used to be thought of as a “male disease,” senior author Marie-Annick Clavel, PhD (Quebec Heart & Lung Institute, Canada), told TCTMD. “That's not the case today,” she added, explaining that women are now known to present differently than men and often don’t have classic symptoms.

“In our population, [men and women had] the exact same severity of the stenosis, but women were less often referred to surgery,” Clavel said. “And if you don't treat the disease, you cannot cure the patient.”

In approaching women with suspected aortic stenosis, especially if questions remain following echocardiography, further investigation is needed to confirm whether the stenosis is severe or not, she stressed. “Because if a patient with a severe stenosis does not undergo an intervention, we know that the prognosis of these patients is really poor.”

“What’s surprising is that in today’s day and age, women still are being referred less for these treatments than men and I’m still not sure why that is,” said Molly Szerlip, MD (Baylor Scott & White Health, Plano, TX), who commented on the study for TCTMD. “I don’t know if it’s because maybe the women didn’t come back. Maybe they were referred and they never showed up, or maybe they looked more frail? These are little old women, and maybe their doctors think they look more frail so they think they couldn’t handle an intervention. Maybe it’s a paradigm problem.”

With Treatment, Similar Outcomes

For the study, published online last week in the European Heart Journal, David Bienjonetti-Boudreau, MD (Quebec Heart & Lung Institute), along with Clavel and colleagues prospectively collected echocardiography data from 3,632 patients (42% women) with mild-to-moderate aortic stenosis between 2005 and 2015. Compared with men, women were older, smaller, presented with more symptoms, and had more hypertension and less CAD but also had similar baseline hemodynamic aortic stenosis severity.

Over a mean follow-up of 4.05 years, 29% of the total population died and 70% underwent AVR. After an analysis using inverse-propensity weighting (IPW), women were found to be at greater risk of mortality (IPW-HR 1.91; 95% CI 1.14-3.22) and were also less likely to be referred for AVR, either surgical or transcatheter (IPW-HR 0.88; 95% CI 0.82-0.96). The greater mortality risk in women disappeared when looking exclusively at patients with concordant nonsevere aortic stenosis initially treated conservatively (IPW-HR 1.03; 95% CI 0.63-1.68) and those with concordant severe aortic stenosis initially treated by valve intervention (IPW-HR 1.25; 95% CI 0.71-2.21).

Notably, the researchers point out, women with discordant low-gradient aortic stenosis were more likely to die than men (IPW-HR 2.17; 95% CI 1.19-3.95), potentially because they were less likely to be referred to valve intervention (IPW-Sub-HR 0.83; 95% CI 0.73-0.95).

Clavel said she was surprised to see that women who received interventions had similar outcomes to their male peers. “But that's great,” she said. “That would say that if we treat women right, they are going to have a good outcome.”

“AVR, either performed via transcatheter approach or surgically, should not be denied or delayed in women with symptomatic discordant aortic stenosis, if aortic stenosis has been shown to be severe by alternative imaging, eg, computed tomography,” the authors conclude. Whether surgery or a transcatheter approach would be the better intervention in women needs further investigation, they say, “as women seem to have worse outcomes than men after surgical AVR while better outcomes after transcatheter intervention.”

Going forward, Clavel said she would like to see more research done on the integration of sex differences in clinical guidelines. “We have the degree of calcification that is now in the new guidelines, and I think that's really important,” she said. “I would like to see that really applied in clinical practice. Confirming the true severity of the stenosis is important to assess.”

The solution for now is education for referring physicians and the public about aortic stenosis, especially in women, Szerlip said. “It’s not only teaching men how to treat these women, but women ourselves. A lot of women may not think that they are that sick or don’t think that they need that intervention or don’t want to put the strain on their family. . . . But when they do get treated, they do just as well.”