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Indexing aortic valve area by body surface area increases the prevalence of severe aortic stenosis
  1. Nikolaus Jander1,
  2. Christa Gohlke-Bärwolf1,
  3. Edda Bahlmann2,
  4. Eva Gerdts3,
  5. Kurt Boman4,
  6. John B Chambers5,
  7. Kenneth Egstrup6,
  8. Christoph A Nienaber7,
  9. Terje R Pedersen8,
  10. Simon Ray9,
  11. Anne B Rossebø10,
  12. Ronnie Willenheimer11,
  13. Rolf-Peter Kienzle1,
  14. Kristian Wachtell12,
  15. Franz-Josef Neumann1,
  16. Jan Minners13
  1. 1University Heart Centre Freiburg/Bad Krozingen, Bad Krozingen, Germany
  2. 2Department of Cardiology, Asklepios Clinic St Georg, Hamburg, Germany
  3. 3Institute of Medicine, University of Bergen, Haukeland University Hospital, Bergen, Norway
  4. 4Department of Medicine, Skellefteå, Sweden/Institution of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
  5. 5Cardiothoracic Centre, Guys–St Thomas Hospital Trust, London, UK
  6. 6Department of Medical Research, OUH Svendborg Hospital, Svendborg, Sweden
  7. 7Medizinische Klinik I, Universitätsklinikum Rostock, Rostock, Germany
  8. 8Ullevål, Centre of Preventive Medicine, University of Oslo, Oslo, Norway
  9. 9Department of Cardiology, University Hospitals of South Manchester, Manchester, UK
  10. 10Division of Cardiology, Oslo University Hospital, Aker, Norway
  11. 11Heart Health Group and Lund University, Malmö, Sweden
  12. 12Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
  13. 13Department of Cardiology, University Hospital Basel, Basel, Switzerland
  1. Correspondence to Dr Jan Minners, Department of Cardiology, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland; jminners{at}


Background To account for differences in body size in patients with aortic stenosis, aortic valve area (AVA) is divided by body surface area (BSA) to calculate indexed AVA (AVAindex). Cut-off values for severe stenosis are <1.0 cm2 for AVA and <0.6 cm2/m2 for AVAindex.

Objective To investigate the influence of indexation on the prevalence of severe aortic stenosis and on the predictive accuracy regarding clinical outcome.

Methods Echocardiographic and anthropometric data from a retrospective cohort of 2843 patients with aortic stenosis (jet velocity >2.5 m/s) and from 1525 patients prospectively followed in the simvastatin and ezetimibe in aortic stenosis (SEAS) trial were analysed.

Results The prevalence of severe stenosis increased with the AVAindex criterion compared to AVA from 71% to 80% in the retrospective cohort, and from 29% to 44% in SEAS (both p<0.001). Overall, the predictive accuracy for aortic valve events was virtually identical for AVA and AVAindex in the SEAS population (mean follow-up of 46 months; area under the receiver operating characteristic curve: 0.67 (95% CI 0.64 to 0.70) vs 0.68 (CI 0.65 to 0.71) (NS). However, 213 patients additionally categorised as severe by AVAindex experienced significantly less valve related events than those fulfilling only the AVA criterion (p<0.001).

Conclusions Indexing AVA by BSA (AVAindex) significantly increases the prevalence of patients with criteria for severe stenosis by including patients with a milder degree of the disease without improving the predictive accuracy for aortic valve related events.

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