Asymptomatic aortic stenosis: far reduced mortality with early surgery

  • Kang DH & al.
  • N Engl J Med
  • 9 Jan 2020

  • International Clinical Digest
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Takeaway

  • In asymptomatic aortic stenosis (AAS), early valve replacement bested conservative management for cardiovascular mortality in this trial in Korea.

Why this matters

  • Whether to operate early or wait has been controversial in AAS cases.
  • Replacement is ultimately the sole effective therapy, but how the risks of surgery-related mortality balanced against mortality risks from waiting was unclear.
  • The timing and indications for surgical intervention in asymptomatic patients with severe aortic stenosis remain controversial.

Key results

  • There were no surgery-related deaths.
  • In intention-to-treat analysis, 1% in the surgery group had primary endpoint (composite of operative and cardiovascular mortality).
  • 15% had the primary endpoint in the conservative management group.
  • The HR for mortality with conservative management was 0.09 (95% CI, 0.01-0.67; P=.003).
  • The number needed to treat to prevent 1 cardiovascular death in 4 years was 20.
  • With conservative management, the sudden death cumulative incidence was 4% at 4 years and 14% at 8 years.
  • Hospitalisation for heart failure was also lower with surgical vs conservative management (0% vs 11%).

Study design

  • Multicentre randomised trial of 145 patients (surgery, 73; conservative care, 72) with AAS (but stenosis was “very severe").
  • Funding: Korean Institute of Medicine.

Limitations

  • The severity of the stenosis in this study might preclude generalising to less severe cases.