“Huge Shift” Favoring Interventions in Aortic Stenosis Care May Still Omit Many Elderly Patients

NEW ORLEANS, LA—The advent of TAVR appears to have increased both the number of elderly patients hospitalized for aortic stenosis, as well as the number of interventions they receive, a new analysis shows. However, less than one-fifth of patients 85 years of age or older appear to have received any intervention as of 2013, according to Canadian registry data.

Given the improvement in mortality rates among even the oldest patients who receive TAVR or surgery, the study author believes clinicians need to take a good hard look at these numbers and ask if they are overlooking patients who could benefit.

TAVR was approved for use in select inoperable patients in Canada in early 2011 following results of the PARTNER I trial. The United States followed suit later the same year giving patients with severe aortic stenosis an alternative to surgery or medical therapy.

“There's definitely been a huge shift in the way aortic stenosis patients are looked after over the last 10 years, and it seems that the introduction of TAVR has really incited a lot of that change,” study author Andrew Czarnecki, MD (Sunnybrook Health Sciences Center, Toronto, Canada), told TCTMD. Czarnecki  presented the data in a poster session here at the American Heart Association’s Scientific Sessions 2016.

Using data from 37,970 patients hospitalized with a primary or secondary diagnosis of aortic stenosis between 2004 and 2013 in the Canadian Institutes for Health Information Discharge Abstract Database, Czarnecki and colleagues tracked admissions and mortality through 1 year.

The overall age- and sex-adjusted hospitalization rate for aortic stenosis increased from 36 to 39 per 100,000 over the study period (P < 0.001), but the majority of the change was seen in the cohort of patients 85 years and older where the rate increased from 400 to 516 per 100,000 (P < 0.001). Additionally, the intervention rate—TAVR or SAVR—in patients within 1 year of hospitalization increased from 39% in 2004 to 44% in 2013 overall (P < 0.001), with the greatest increase observed in those patients 85 years and older (5% to 18%; P < 0.001).

“What's encouraging is that outcomes have generally improved in patients who receive intervention,” Czarnecki said. “The flip side of that, of course, is that in this dataset the majority of patients still aren't getting an intervention, which I think was a bit of a surprise to us.” A limitation of the study was the lack of echocardiography and symptoms data, he continued, so “we can't say how many of those patients should have had an intervention [and didn’t], . . . but it's probably less than we would have expected to see.”

Czarnecki noted that the increase in both hospitalizations and interventions coincided with the introduction of TAVR—still experimental—in 2008 and 2009.

Lastly, overall unadjusted 30-day and 1-year mortality rates after hospitalization were 12% and 26%, respectively, and these metrics remained stable over the study period. But in patients who received TAVR or surgery, adjusted mortality improved over time, though this was not the case for patients who did not receive an intervention.

Going forward, Czarnecki hopes that physicians do a better job of examining their practices and the take note of the “large portion of patients” who aren’t receiving interventions. “Are there patients who we are just not offering this to?” he asked. This question will be important in terms of future resource planning given the expense of the devices and potentially underserved demographics within Ontario and more globally.