• aortic stenosis
• healthcare delivery

Guidelines only improve care if they are read and implemented. In the 16 years since the first EuroHeart Survey,1 there have been seven American Heart Association and European Society of Cardiology guidelines on heart valve disease. Despite these, the report from the IMPULSE registry in this issue of Heart2 shows that service delivery for patients with severe aortic stenosis (AS) is still inadequate. Nearly one-quarter, 24%, with indications for intervention were planned for conservative management while 36% had a decision for intervention apparently without a recognised indication. Overall, 26% received apparently inappropriate treatment decisions which is similar to the 30% shown by the first EuroHeart survey.1

The IMPULSE registry, funded by Edwards Lifesciences, is a prospective international multicentre registry-based cohort study evaluating the care of patients with severe AS3 in 23 centres in 9 European countries. It originally aimed to test an intervention designed to improve decision-making using three different cohorts of patients. In the first cohort, entered onto the database during months 0–3, demographic data would be collected prospectively. The referring physician would be contacted at 3 months after enrolment for details of the treatment plan. For patients entered during the intervention period during months 4–9, the study nurse would inform the referring physician 1 week after the diagnosis of severe AS was made in the echocardiography laboratory …