Increased mortality in women with severe aortic stenosis and low ejection fraction. (25th November 2020)

• Record Type: Journal Article
• Authors: Paquin, A; Annabi, M.-S; Bienjonetti-Boudreau, D; Pibarot, P; Clavel, M.-A
• Is Part Of: European heart journal. Volume 41:(2020)Supplement 2
• Publication Date: 2020-11-25
• Subjects: Cardiovascular Disease in Women; Cardiology -- Periodicals; Heart -- Diseases -- Periodicals; 616.12005
• DOI: 10.1093/ehjci/ehaa946.3170
• Languages: English
• ISSNs: 0195-668X

Abstract

Abstract: Background: Women with severe aortic stenosis (AS) tend to be operated with more advanced valvular heart disease. They also have worse survival after aortic valve replacement (AVR). This difference between sexes in surgical referral and its relationship to mortality have not been previously studied in patients with severe AS and low left ventricular ejection fraction (LVEF). Purpose: To assess sex differences in patients with severe AS and low LVEF, and to evaluate their potential association with mortality. Methods: This is a retrospective study of consecutive patients presenting with a diagnosis of severe AS and low LVEF (≤50%) on echocardiogram, at the Quebec Heart and Lung Institute between 2004–2015. Patients were excluded if they had congenial or rheumatic heart disease, and/or more than moderate aortic regurgitation. Patients were compared according to sex for incidence of AVR and long-term all-cause mortality with univariate (Kaplan-Meyer with log-rank test), and multivariate analysis (Cox regression model) adjusting for baseline comorbidities, LVEF and severity of valvular disease. Results: Our database had a total of 1129 patients, of which 578 were included in the analysis. There were 149 women (26%). Mean follow-up time was 3.10±3.04 years (1795 patient-years). There were 279 AVR and 284 deaths. Women were older (77±11 vs 74±10 years, p=0.004), and had less coronary artery disease (60% vs 79%, p<0.001) and dyslipidemia (55% vs 72%, p<0.001). Women had comparable severity of AS at baseline, with better LVEF (37% vs 35%, p=0.02). In univariate analysis, there was a strong tendency for increased mortality in women compared to men (p=0.06). After comprehensive baseline adjustement, female sex was predictive of mortality (HR 1.33 [1.00–1.75], p=0.04). Women were also less likely to be operated than men (HR 0.70 [0.51–0.94], p=0.02). After further adjustment for AVR as a time-dependent variable, there was only a trend toward the significance of sex as a predictor of mortality (p=0.12). In a sex-specific analysis of predictors of mortality, LVEF was predictive of mortality in women (HR 0.97 [0.94–0.99], p=0.007), while not in men (0.99 [0.98–1.01], p=0.51). Conclusions: Despite adjustment for comorbidities and AS severity, women were less likely to be referred to AVR and had a higher overall mortality. After adjustment for AVR, female sex was no longer a predictor of mortality, underlying the negative impact of the lack of treatment in women with decreased LVEF. Thus underrecognition and suboptimal management of severe AS in female patients with low LVEF should be further investigated to identify contributing factors and possible solutions. Funding Acknowledgement: Type of funding source: Public Institution(s). Main funding source(s): Dr Clavel has received a grant from the Heart and Stroke Foundation of Canada