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Meta-analysis of the impact of intervention versus symptom-driven management in asymptomatic severe aortic stenosis
  1. Wei Yao Lim1,
  2. Anantharaman Ramasamy1,
  3. Guy Lloyd1,2,3,
  4. Sanjeev Bhattacharyya1,2,3
  1. 1Echocardiography Laboratory, Barts Heart Centre, St Bartholomew's Hospital, London, UK
  2. 2Valvular Heart Disease Clinic, Barts Heart Centre, St Bartholomew's Hospital, London, UK
  3. 3Institute of Cardiovascular Science, University College London, London, UK
  1. Correspondence to Dr Sanjeev Bhattacharyya, Echocardiography Laboratory & Valvular Heart Disease Clinic, Barts Heart Centre, St Bartholomew's Hospital, Institute of Cardiovascular Sciences, UCL, London EC1 7AB, UK; Sanjeev.Bhattacharyya{at}bartshealth.nhs.uk

Abstract

Objective The management of patients with asymptomatic, severe aortic stenosis (AS) is controversial. We performed a meta-analysis to examine the impact on outcomes of aortic valve replacement (AVR) in patients with severe asymptomatic AS versus a symptom-driven intervention approach.

Methods A search for studies that examined the outcomes of AVR and management of asymptomatic severe AS was performed. We examined the end points of all-cause mortality, cardiac mortality and sudden cardiac death. Our analysis compared early AVR in asymptomatic patients with a symptom-driven AVR approach (excluding symptomatic patients who did not undergo AVR).

Results Four observational studies were identified with a total of 1300 patients. There was significant heterogeneity between studies (I2=72%). Using a random-effects model, there was a trend towards reduced overall mortality in patients undergoing early AVR compared with a symptom-driven AVR approach (OR 0.54, 95% CI 0.26 to 1.12, p=0.1). There was no significant reduction in cardiac mortality or sudden death (OR 0.78, p=0.85, and OR 0.34, p=0.25, respectively).

Conclusions Although there was a trend towards reduced overall mortality when comparing early AVR in patients with asymptomatic, severe AS to a symptom-driven AVR approach, there was no significant difference in cardiac mortality or sudden death. An individual approach focusing on individual risk stratification and operative mortality is required until more robust, randomised trial data are available.

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