Aortic Stenosis Connect recently hosted a discussion with cardiologists regarding the treatment of aortic stenosis (AS).

Below are some highlights from the discussion:

Patients with AS who are candidates for aortic valve replacement (AVR) but are not receiving any type of AVR are going unrecognized.

• “AS continues undertreated due to lack of referrals to cardiology as patients may remain relatively asymptomatic for prolonged periods of time.”
• “Low-gradient AS is difficult to diagnose and is often overlooked.”

Patients who need urgent transcatheter aortic valve replacement (TAVR) are typically sicker and present with more comorbidities than their counterparts who undergo elective TAVR.

• “Urgent TAVR is performed in acutely hospitalized patients often with multiple concomitant conditions, frequently presenting with acute events. More frequently, these patients have chronic kidney disease or diabetes mellitus and, thus, have increased morbidity.”

Physicians need better awareness and recognition of AS, and closer follow-up is needed.

• “The recognition can be improved by more frequent follow ups with ACPs and cardiologists who are trained to know what to look for and to also very carefully educate patients. Echocardiography is not helpful as no one can define a more frequent screening process since emergencies are by rule emergent and cannot be screened for. But an acute decompensation will usually be caused by either ischemia or third spacing of fluid postprocedure or rarely an acute thrombus or dysfunction of the valve. This is why close follow-up is very important.”

One respondent discussed that the threshold for referral of severe AS should not depend on whether the patient was symptomatic or asymptomatic.

• “Patients with severe AS should be evaluated to a heart valve team for evaluation and follow-up. This is true whether the patient is considered to be symptomatic or not—as a heart valve team may be able to further evaluate with methods including stress test, proBNP, LV strain, and serial imaging to detect changes in LVEF that will allow earlier recognition of concern and appropriate triage for AVR.”

However, one respondent said that they approach asymptomatic cases differently.

• “For me, severe symptomatic AS is the threshold for referral. Asymptomatic, very severe AS, and asymptomatic severe AS with a drop in ejection fraction also prompt referral. Severe AS with absolutely no symptoms, a normal BNP, and normal exercise tolerance prompts repeat echocardiogram in 6 months along with close clinical follow-up.”

Using chronologic age rather than physiologic age and functional status as assessment factors were barriers to referral.

• “Many providers are still focusing on age as one of the main factors to determine patient candidacy for treatment rather than their functional status, KCCQ data, etc.”
• “Chronologic age is rather unimportant, and physiologic age and functional status are more appropriate factors in assessment of whom to refer for AVR; certainly more elderly patients can be candidates for TAVR than for SAVR if functionally acceptable candidates (including nonoctogenarians).”

Older women are at risk for underrecognition, and other disparities exist that cause poor access for referral.

• “Usually the older female demographic [is underrecognized or missed for referral to the heart valve team].”
• “I think a lot of it has to do with access to care. Rural patient populations, poor patients, and those in underserved areas are probably less likely to be referred for valve therapies then people who are in affluent, well-educated, overserved areas.”

Respondents agreed that a multidisciplinary approach is key to optimizing outcomes and shared decision-making.

• “Members of the heart team and the general cardiologists must work together—the general cardiologist to recognize AS and follow appropriately and refer expeditiously when needed for consideration of AVR and the heart valve team with open communication about recommendations, treatment, and follow-up after AVR. When communication is open, outcomes are best.”
• “The approach truly needs to be multidisciplinary and should occur on a regular basis at a time when it is convenient for the members of this group to get together. All cases should be discussed in detail with a recommendation made on a prompt basis.”

Artificial intelligence (AI) was recommended to help shorten the time from diagnosis to treatment and identify at-risk patients and help mitigate physicians’ underrecognition of severe AS.

• “I think that we need AI to screen echocardiograms and determine who has severe AS, potentially automating the referral. Additionally, using AI and deep learning to scrape charts for symptoms and get clues off of ECGs potentially would also shorten time to diagnosis.”
• “Using AI is the way to go here. Use a backdrop of a large database of patients and feed into the system what their final outcome was using other tests and also their outcomes post -TAVR. This provides a strong probability of identifying patterns on ECHOs that will benefit from AVR.”