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Original research
Cumulative burden of clinically significant aortic stenosis in community-dwelling older adults
  1. David S Owens1,
  2. Traci M Bartz2,
  3. Petra Buzkova2,
  4. Daniele Massera3,
  5. Mary L Biggs2,
  6. Selma D Carlson4,
  7. Bruce M Psaty5,
  8. Nona Sotoodehnia1,5,
  9. John S Gottdiener6,
  10. Jorge R Kizer7,8
  1. 1Department of Medicine, Division of Cardiology, University of Washington, Seattle, Washington, USA
  2. 2Department of Biostatistics, University of Washington, Seattle, Washington, USA
  3. 3Leon H. Charney Division of Cardiology, Department of Medicine, NYU Langone Health, New York, New York, USA
  4. 4Division of Cardiology, Department of Medicine, Minneapolis Veterans Affairs Medical Center and University of Minnesota School of Medicine, Minneapolis, Minnesota, USA
  5. 5Cardiovascular Health Research Unit, Departments of Medicine, Epidemiology and Health Services, University of Washington, Seattle, Washington, USA
  6. 6Division of Cardiology, Department of Medicine, University of Maryland, Baltimore, Maryland, USA
  7. 7Cardiology Section, San Francisco VA Health Care System, San Francisco, California, USA
  8. 8Departments of Medicine, Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
  1. Correspondence to Dr Jorge R Kizer, San Francisco VA Health Care System, San Francisco, California, USA; jorge.kizer{at}


Objectives Current estimates of aortic stenosis (AS) frequency have mostly relied on cross-sectional echocardiographic or longitudinal administrative data, making understanding of AS burden incomplete. We performed case adjudications to evaluate the frequency of AS and assess differences by age, sex and race in an older cohort with long-term follow-up.

Methods We developed case-capture methods using study echocardiograms, procedure and diagnosis codes, heart failure events and deaths for targeted review of medical records in the Cardiovascular Health Study to identify moderate or severe AS and related procedures or hospitalisations. The primary outcome was clinically significant AS (severe AS or procedure). Assessment of incident AS burden was based on subdistribution survival methods, while associations with age, sex and race relied on cause-specific survival methods.

Results The cohort comprised 5795 participants (age 73±6, 42.2% male, 14.3% Black). Cumulative frequency of clinically significant AS at maximal 25-year follow-up was 3.69% (probable/definite) to 4.67% (possible/probable/definite), while the corresponding 20-year cumulative incidence was 2.88% to 3.71%. Of incident cases, about 85% had a hospitalisation for severe AS, but roughly half did not undergo valve intervention. The adjusted incidence of clinically significant AS was higher in men (HR 1.62 [95% CI 1.21 to 2.17]) and increased with age (HR 1.08 [95% CI 1.04 to 1.11]), but was lower in Blacks (HR 0.43 [95% CI 0.23 to 0.81]).

Conclusions In this community-based study, we identified a higher burden of clinically significant AS than reported previously, with differences by age, sex and race. These findings have important implications for public health resource planning, although the lower burden in Blacks merits further study.

  • epidemiology
  • aortic valve stenosis

Data availability statement

Data are available from the authors on reasonable request.

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Data availability statement

Data are available from the authors on reasonable request.

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  • Contributors Planning for this research was conducted by DSO, BMP, JSG and JRK. The project was conducted by DSO, TMB, PB, DM, MLB, SDC, NS, BMP, JSG and JRK. All authors were involved in reporting the work. JRK serves as guarantor. The corresponding author has the right to grant on behalf of all authors and does grant on behalf of all authors, an exclusive license (or non-exclusive for government employees) on a worldwide basis to the BMJ Publishing Group Ltd and its Licensees to permit this article (if accepted) to be published in HEART editions and any other BMJPGL products to exploit all subsidiary rights.

  • Funding This research was supported by contracts HHSN268201200036C, HHSN268200800007C, HHSN268201800001C, N01HC55222, N01HC85079, N01HC85080, N01HC85081, N01HC85082, N01HC85083, N01HC85086, 75N92021D00006, and grants U01HL080295 and U01HL130114 from the National Heart, Lung, and Blood Institute (NHLBI), with additional contribution from the National Institute of Neurological Disorders and Stroke (NINDS). Additional support was provided by R01AG023629 from the National Institute on Aging. DSO was supported by a Mentored Clinical and Population Research Award from the American Heart Association’s Western States Affiliate. DM was supported by the Glorney-Raisbeck Fellowship Program, Corlette Glorney Foundation and the New York Academy of Medicine. JRK was supported by K24 HL135413 from the National Heart, Lung, and Blood Institute. A full list of principal CHS investigators and institutions can be found online (

  • Competing interests JRK discloses stock ownership in Abbott, Bristol-Myers Squibb, Johnson & Johnson, Medtronic, Merck and Pfizer.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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