Stepwise increase in mortality and re-hospitalization with accumulating markers of social inequity after TAVI– a nationwide cohort study
V Mikkelsen, J K Petersen, M Meibom, L M Soerensen, M Schou, L Koeber, O de Backer, E L FosboelAbstract
Background
Transcatheter aortic valve implantation (TAVI) is increasingly recommended across a broad spectrum of patients with severe aortic stenosis, yet the prognostic impact of social inequity remains poorly characterized.
Purpose
To examine all-cause mortality and cumulative all-cause hospitalization days after TAVI according to the cumulative burden of markers of social inequity.
Methods
In this nationwide registry-based cohort study, we included all adults undergoing first-time TAVI in Denmark between 2015 and 2023. Patients were categorized by number of social inequity markers (0, 1, 2, ≥3). Markers included domiciliary care, polypharmacy, age ≥85 years, intermediate/high frailty (ICD-10), non-Western immigrant status, mental illness, rural residence, and living alone. Outcomes were one-year all-cause mortality after TAVI and cumulative hospitalization days within one year after discharge. Cumulative hospitalization days were categorized as 0, 0-14 or >14 days and analyzed using multivariable logistic regression. Mortality was analyzed using Kaplan-Meier estimates and multivariable Cox regression. All Models were adjusted for sex, calendar period, and comorbidities.
Results
Among 7,607 patients undergoing TAVI, 806 (10.6%) had 0 markers of social inequity (28% female; median age 79 years), 1,966 (25.8%) had 1 marker (33.6% female; median age 80 years), 2,149 (28.3%) had 2 markers (40.4% female; median age 81 years), and 2,686 (35.3%) had ≥3 markers (53.7% female; median age 84 years). Increasing markers of social inequity were associated with a higher comorbidity burden and a graded increase in mortality. One-year mortality was 9.3% in patients with ≥3 markers versus 3.6%, 6.3%, and 6.1% in those with 0, 1, and 2 markers, (Panel A). In multivariable analyses, the presence of ≥3 markers of social inequity were independently associated with increased one-year mortality with HR 2.04, (95% CI 1.35–3.00). In adjusted analyses of one-year mortality, the following individual markers were associated with higher hazard ratios: domiciliary care with HR 3.35 (95% CI 2.69-4.18), polypharmacy with HR 1.47 (95% CI 1.23-1.75), ≥85 years with HR 1.28 (95% CI 1.06-1.54), frailty with HR 1.28 (95% CI 1.06-1.54), and non-Western immigrant status with HR 1.27 (95% CI 0.63-2.57), (Panel B). Additionally, ≥3 markers of social inequity were independently associated with increased odds of prolonged hospitalization (>14 cumulative days) within 1 year after TAVI, with OR 2.26 (95% CI 1.71-2.99), (Panel C).
Conclusions
A higher burden of markers of social inequity were associated with greater comorbidity and increased mortality following TAVI. Domiciliary care and polypharmacy emerged as the strongest markers of adverse outcomes. These findings suggest that markers of social inequity capture prognostic information beyond traditional clinical risk factors and may support more comprehensive risk stratification in TAVI populations.Social inequity figures