Aortic Stenosis Patients Still Tripped Up by Diagnosis Issues on the Path to AVR

NEW YORK CITY — People with aortic stenosis (AS) were increasingly getting timelier diagnosis, though treatment delays persisted in a national care quality registry study.

U.S. patients flagged with moderate or severe AS, based on an initial echocardiogram, ended up getting all their confirmatory diagnostic assessments within 30 days in 61.4% of cases in 2024, up from 54.2% in 2023 (P=0.001), per the American Heart Association’s Target: Aortic Stenosis registry.

Among those with a class I indication for aortic valve replacement (AVR), the goal of timely treatment was achieved by 84.7% in 2024, no significant change from 82.2% the year before. This meant that nearly one in six eligible individuals did not get AVR within 90 days, according to Brian Lindman, MD, MSc, of Vanderbilt University Medical Center in Nashville, Tennessee.

The registry study, based on randomly selected patients from 58 participating American sites, was presented at the New York Valves annual meeting hosted by the Cardiovascular Research Foundation. Its manuscript was simultaneously published in Circulation.

“There were significant gaps in care that were identified through these registry metrics. Nonetheless, we also did see improvement, particularly with respect to the primary one of the co-primary measures of timely diagnosis and its components as we move forward to address additional gaps in care,” Lindman concluded.

Gaps in upstream AS care can be viewed as barriers to effective aortic interventions, namely surgery and the transcatheter aortic valve replacement (TAVR) procedures now considered firmly established in clinical practice.

“Over the past two decades, we witnessed a remarkable transformation in the care of patients with aortic stenosis. It has gone from a condition with about 50% 1-year mortality in the pre-TAVR era to approximately 1-2% 1-year mortality in the low-risk TAVR era,” said session discussant Dharam Kumbhani, MD, of UT Southwestern Medical Center in Dallas. “The Target AS registry represents an important advance in moving beyond procedural excellence towards excellence across the entire continuum of aortic stenosis care.”

Notably, this registry report comes in the aftermath of proposed changes to the federal oversight of TAVR. Earlier this month, CMS had released a proposed national coverage determination for TAVR that would:

• Remove Coverage with Evidence Development (CED) requirements for symptomatic severe AS
• Implement coverage for TAVR for asymptomatic severe AS under CED
• Remove the requirement that TAVR procedures be performed by both an interventional cardiologist and a cardiac surgeon
• Eliminate facility-level procedural volume requirements

An expansion of TAVR may be expected with this proposed loosening of the rules.

Under the current system, hospitals have been stretched by the demand for TAVR, resulting in longer wait times. Of note, prior studies have suggested increased wait-time mortality during periods of rapid adoption of TAVR, which has been thought to explain the overall uptick in AS deaths in recent years.

Now, based on Lindman’s report, there are also upstream issues related to the lack of timely symptom assessment and lack of stroke volume index reporting or multimodality testing to clarify AS severity for a diagnosis.

“Understanding why approximately one in six patients still experience treatment delays is important, particularly given the known adverse outcomes with untreated severe aortic stenosis and the known access barriers in many situations,” said Kumbhani.

Similarly, fellow panelist Roxana Mehran, MD, of Mount Sinai Health System in New York City, cited concerns about “access and timely treatment in vulnerable patients and women.”

Target: Aortic Stenosis is notable for being the first national registry to provide data and evaluate quality for upstream processes of care for patients with AS. It is being expanded to the Heart Valve Initiative, Lindman said, the goal being to eventually increase to 200 sites and expand to other heart valve diseases such as mitral regurgitation and tricuspid regurgitation.

The present analysis covered 58 sites, of which 26 had at least 40 patients entered in both 2023 and 2024; there were 12 sites that had joined the initiative prior to 2023.

Included patients, randomly sampled based on echocardiogram data, were 8,097 individuals (median age 76.5 years, 47% women).

There were 5,821 patients with definite or possible severe AS echocardiograms, of which 3,380 had confirmed severe AS based on testing. With symptom assessments, the pool with a class I indication for AVR narrowed to 2,664 people, according to Lindman and colleagues.

He acknowledged that the registry study lacked long-term follow-up and was subject to bias in the patient sampling. Patients who wanted some delay, or futile cases, were exempt from the timely treatment analysis, he also cautioned.