Severe Aortic Stenosis Gets Its Own Appropriate Use Criteria

Severe aortic stenosis is now the latest cardiovascular condition to be granted a set of appropriate use criteria (AUC), joining the ranks of acute coronary syndromes and stable ischemic heart disease, among others.

The nonbinding standards, published online October 17, 2017, ahead of print in the Journal of the American College of Cardiology, are meant to guide decision-making but not dictate choices or determine reimbursement, writing committee chair Robert O. Bonow, MD (Northwestern University, Chicago, IL), told TCTMD.

With all the moving parts involved in caring for people with aortic stenosis and the growing number of patients being referred for either transcatheter or surgical aortic valve replacement (SAVR), the time was right for dedicated AUC, Bonow said. “In some cases, one intervention might be preferred over another depending on the circumstances. And in some cases, it’s totally appropriate to do nothing but medical management or wait until patients have a stronger indication for intervention.”

Not a Competition

Yet this isn’t a horse race: TAVR, SAVR, and medical management aren’t competing directly against each other in the aortic stenosis AUC, which were developed by the American College of Cardiology and several other societies, Bonow explained. Rather, they are judged on their own merits for each clinical scenario. In all, there are 95 indications listed, with advice on how to:

• Treat patients who are asymptomatic
• Take into account flow, gradient, and ejection fraction
• Weigh the importance of comorbidities and frailty
• Handle concomitant CAD or other types of valve disease
• Make decisions when noncardiac surgery is anticipated
• Address failing aortic valve bioprostheses

The AUC provide a “foundation” for clinicians trying to decide next steps in caring for patients with severe aortic stenosis, Bonow said, adding, “Guidelines are helpful [and] provide lots of recommendations,” but often don’t fully address how to handle an individual patient’s circumstances. Moreover, the goals of care—such as prolonging or improving quality of life—can vary from case to case, as can the risks.

Another factor to consider is where patients are receiving care, he commented. “If you’re in a hospital which has credible quality for surgery and has not yet evolved TAVR, or vice versa, [this affects decisions]. You kind of play to your strengths.”

Bonow predicted few of the aortic stenosis AUC would generate controversy, in large part because they follow the terminology of previous documents: appropriate, may be appropriate, or rarely appropriate. For “red boxes” on the grid—denoting “rarely appropriate”—what’s important is to have open discussions with patients and to thoroughly document decisions that are made, he advised. On the flip side, just because a treatment is considered appropriate does not make it mandatory.

One of the challenges in developing the new AUC was that the treatment of aortic stenosis is a “moving target,” Bonow observed. “When we first started writing this, intermediate-risk [TAVR] was not yet approved. The trials had not been published. So, in the first couple of iterations of the document, the intermediate-risk patient was ‘rarely appropriate’ and now it’s very appropriate, because the trials have been completed and the guidelines have changed and the payment options have changed, too.”

Further evolutions in the AUC will be seen when data on low-risk patients become available, he predicted.