PRIORITY-AS: a novel score to predict adverse outcomes in patients with high-gradient aortic stenosis
M Duarte Almeida, J G Fiuza, F R Santos, G R M Ferreira, O C Kungel, L A Santos, N CraveiroAbstract
Introduction
Severe high-gradient aortic stenosis (AS) is a life-threatening condition with a poor prognosis if left untreated. With an aging population and increased diagnostic accessibility, the prevalence of AS has risen sharply. The growing disparity between patients requiring intervention and healthcare system capacity has led to prolonged waiting lists. Therefore, identifying variables that define clinical priority is essential to ensure equitable and timely access to intervention.
Purpose
This study aimed to characterize patients referred for aortic valve intervention, analyse the referral process, and identify predictors of adverse outcomes while on the waiting list.
Methods
We included patients with severe high-gradient AS referred for intervention between January and December 2022. The primary composite endpoint was defined as all-cause mortality, unplanned hospitalization, or emergency department visits requiring intravenous diuretics for decompensated heart failure within one year of referral (or until intervention). Predictors were analysed using Chi-square and Independent t-tests. A predictive score was developed based on significant variables.
Results
A total of 95 patients were included (48.4% female; mean age 75.5 ± 8.0 years). The primary endpoint occurred in 21.1% (n=20) of the cohort. Patients who reached the endpoint were significantly older and had higher rates of smoking and paroxysmal nocturnal dyspnoea. Echocardiographic predictors included lower Left Ventricular Ejection Fraction (LVEF), higher Pulmonary Artery Systolic Pressure (PASP), and lower TAPSE. Optimal ROC cut-offs identified: age ≥73 years (Sn 90%, Sp 37%), LVEF ≤53% (Sn 86%, Sp 40%), PASP ≥36.5 mmHg (Sn 60%, Sp 72%), and TAPSE ≤20.5 mm (Sn 70%, Sp 60%). A 6-point risk score was created (1 point each for: age ≥73, smoking, paroxysmal nocturnal dyspnoea, LVEF ≤53%, PASP ≥36.5 mmHg, and TAPSE ≤20.5 mm). Patients with adverse outcomes had significantly higher scores (2.6 ± 1.4 vs. 1.3 ± 1.0; p<0.001). Each point increase in the score was associated with a 2.5-fold increase in the risk of the primary endpoint (OR 2.5; 95% CI 1.51–4.02; p<0.001). The score showed moderate discriminative capacity with an AUC of 0.745 (95% CI 0.62–0.87; p=0.001).
Conclusion
A simple score combining clinical and echocardiographic data can effectively risk-stratify patients with severe AS. This tool may be pivotal in prioritizing patients on surgical or percutaneous intervention waiting lists to reduce mortality and urgent hospitalizations.For image description, please refer to the figure legend and surrounding text.For image description, please refer to the figure legend and surrounding text.