Dissociation between haemodynamic progression and mortality in moderate aortic stenosis

Background

Moderate aortic stenosis (AS) in elderly patients is heterogeneous, and survival is often influenced by non-cardiovascular comorbidities. The prognostic significance of haemodynamic progression in this population remains unclear.

Methods

We retrospectively analysed 329 patients with newly diagnosed moderate AS (2015–2016), excluding mild AS, bicuspid valves, and significant concomitant valvular disease. A subgroup of 186 patients with long-term follow-up was stratified by progression to severe AS: rapid (≤3 years), intermediate (4–9 years), or non-progressors (≥10 years). Associations between baseline characteristics, progression, and mortality were assessed over a median follow-up of 59 months (IQR 19–105).

Results

Mean age was 78±10 years and 53% (174/329) were male. Overall, 30% (99/329) of patients progressed to severe AS; older age and higher baseline mean gradient independently predicted progression (p<0.05). Rapid progressors had higher baseline Vmax and mean gradients despite similar aortic valve area. Overall mortality was high (79.6%) and predominantly non-cardiovascular. Patients with stable moderate AS exhibited a higher all-cause mortality rate than those who progressed to severe AS (83.5% vs. 70.7%, p = .008). (Figure 1) Similarly, a higher incidence of cardiovascular death was observed in the stable moderate group (16.5% vs. 15.2%, p = .030).

In our subgroup analysis, non-progressors had the highest mortality (89.8%) compared with rapid (72.5%) and intermediate (68.9%) progressors (p=0.007). Cardiovascular mortality was low overall (8–16%).(Figure 2)

Conclusion

In elderly moderate AS, haemodynamic progression is common but does not predict overall mortality, which is largely driven by non-cardiovascular comorbidity. The shorter survival among non-progressors reflects competing-risk effects, demonstrating a dissociation between disease progression and survival. These findings question the prognostic value of haemodynamic trajectory alone and emphasize the need for holistic patient assessment when guiding management strategies.Survival outcomes 1Survival outcomes 2