Watchful waiting in aortic stenosis: the problem of acute decompensation
American Journal of Medicine
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Background Acute decompensation with heart failure, angina or syncope may be the first indication of undiagnosed aortic stenosis, but should be uncommon when the disorder is known and managed by watchful waiting. There is a lack of information on the proportion of patients with acute decompensated aortic stenosis with and without a prior diagnosis and their outcomes. Methods We examined the records of patients with aortic stenosis (ICD code 135.0) admitted to three UK hospitals between January 2015 and January 2016. We determined the number of admissions with acute decompensation and the proportion in whom aortic stenosis was and was not previously known. The characteristics and outcomes in the two groups were compared. Results Out of 684 patients with aortic stenosis, 543 (79%, (95% CI 76%-82%)) were elective admissions and 141 (21% (18-24%)) were emergencies with acute decompensation; 86/141 (61% (52%-69%)) with known aortic stenosis under watchful waiting and 55/141 (39% (31%-48%)) without a prior diagnosis. In-hospital mortality was 16% v 13% respectively (p=0.48). There were no statistically significant differences in characteristics or clinical presentation between the two groups (p>0.1 for all comparisons). Conclusion About 1 in 5 patients admitted to hospital with aortic stenosis have life-threatening complications due to their disorder. Over half of such patients are actively monitored for aortic stenosis before admission, exposing shortcomings of the watchful waiting management strategy. Measures to identify symptomatic patients earlier and shorten the time between symptom onset and surgery have the potential to substantially reduce morbidity and mortality.
AuthorsWALD, D; Williams, S; Bangash, F; bestwick, J
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