Tackling Undertreatment of Serious Heart Valve Disease

Aortic stenosis (AS) is one of the most common and serious heart valve disease problems. More than 1.7 million Americans over age 65 have severe aortic stenosis, and without valve replacement, as few as half survive beyond two years1.

Over time, calcium can build up in the aortic valve—the valve between the heart’s main pumping chamber and the aorta—narrowing its opening and restricting blood flow to the heart. This narrowing can weaken the heart, causing fatigue, shortness of breath, chest pain and rapid, fluttering heartbeat2.

Early treatment is key to preventing heart failure, but many people with AS are unaware or undiagnosed. Those with milder severities can be treated with lifestyle changes or medication, but severe cases might require a valve procedure and it is recommended they are evaluated by a multidisciplinary heart team. 

“Twenty years ago, the standard for care of severe AS cases was surgical aortic valve replacement (SAVR), but even in the best cases, recovery from the procedure was challenging” said Brian Lindman, M.D., MSCI, American Heart Association volunteer expert and medical director of the Structural Heart and Valve Center and associate professor of medicine at Vanderbilt University Medical Center in Nashville, Tennessee. “Thanks to innovative research and updated evidence-based guidelines, many patients today can benefit from a less invasive procedure with an easier recovery.”

About two decades ago, the options for patients with aortic stenosis dramatically changed. Through a procedure called transcatheter aortic valve implantation (TAVI), researchers were able to successfully insert a closed artificial valve (prosthesis) via catheter and expand it to function in place of the diseased valve. Recovery time is significantly shorter than the traditional SAVR method because the minimally invasive procedure allows insertion of the replacement valve without removing the damaged natural valve. Less recovery time reduces financial and physical costs for patients and frees up beds so hospitals can treat more people.

Research shows TAVI treatment has overtaken surgical replacements, with 72,991 TAVI procedures performed in 2019 compared with 57,626 SAVR replacements, showing the TAVI procedure meets the needs of many people for whom surgery would be risky3.

Despite the advancement of TAVI, fewer than half of patients with severe AS receive treatment within a year of developing symptoms, according to a 2022 study in the Journal of the American College of Cardiology. For those from underrepresented racial and ethnic groups, undertreatment is even more prevalent4. For this technique to benefit patients, clinicians must first facilitate timely identification and diagnosis of the condition, which requires professional education offering a better understanding of AS.

“With sufficient awareness, health care professionals have an opportune moment during annual physicals to raise questions about AS symptoms and ask about the patient’s history of heart murmur – efforts that can allow for cardiovascular imaging,” Lindman said. “With a foundational understanding of AS, health care organizations can optimize treatment pathways and referrals to ensure patients receive the right level of care at the right time.”

The American Heart Association continues to drive efforts for timely diagnosis, appropriate treatment, improved quality of care initiatives and comprehensive patient and caregiver resources to combat the disease. To help improve provider understanding of the issue, the Association in 2020 launched Target: Aortic Stenosis™. The goal of the Target: Aortic Stenosis program, supported by national sponsor Edwards Lifesciences, is to enhance the patient experience from symptom onset to appropriate diagnosis and follow-up, to timely treatment and disease management. The program consists of evidence-based measurement development to better identify and treat patients, as well as multimedia educational resources and self-management care plans for people living with structural heart disease.

“This program aims to improve understanding of AS and optimize treatment pathways, as well as encourage further research,” Lindman said. “Shared decision-making is key in this effort. We must bring together the patient, caregivers, patient advocates, the nurse practitioner, interventionalists, primary care physician and heart team to determine the best path forward.”

More information on the American Heart Association’s Target: Aortic Stenosis program can be found at www.heart.org/TargetAS.

1 Owens DS, Bartz TM, Buzkova P, et al, Cumulative burden of clinically significant aortic stenosis in community-dwelling older adults. Heart. 2021;107:1493-1502.

2 DS-16738 Aortic Stenosis Fact Sheet (heart.org)

3 STS-ACC TVT Registry of Transcatheter Aortic Valve Replacement - PubMed (nih.gov)

4 Li SX, Patel NK, Flannery LD, Selberg A, Kandanelly RR et al. (2022) Trends in utilization of aortic valve replacement for severe aortic stenosis. J Am Coll Cardiol 79 (9): 864-877.

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