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Aortic Stenosis in the Elderly: Disease Prevalence and Number of Candidates for Transcatheter Aortic Valve Replacement: A Meta-Analysis and Modelling Study
Study Questions:
What is the current prevalence of aortic stenosis (AS) in elderly individuals, and what proportion of these patients may be candidates for transcatheter aortic valve replacement (TAVR)?
Methods:
This meta-analysis included data from seven studies totaling 9,273 patients, and pooled the prevalence of AS in elderly individuals (>75 years of age). A model of potential TAVR candidates was generated using a separate systematic literature search examining decision-making studies of AS patients. This latter model incorporated the proportion of patients with severe AS who were symptomatic, the proportion of patients with severe symptomatic AS who did not receive surgical aortic valve replacement (SAVR) and who may be TAVR candidates, the proportion of patients referred for TAVR who underwent the procedure, and the proportion of high-risk individuals who underwent SAVR, but who may be candidates for TAVR.
Results:
The pooled prevalence of any AS in the elderly was 12.4% (95% confidence interval [CI], 6.6-18.2%), and the pooled prevalence of severe AS was 3.4% (95% CI, 1.1-5.7%). In elderly patients with severe AS, 75.6% (95% CI, 65.8-85.4%) were symptomatic. Among elderly patients with severe symptomatic AS, 40.5% (95% CI, 35.8-45.1%) were not treated with SAVR and may be candidates for TAVR. Of the patients referred for TAVR, only 28.7% (95% CI, 22.8-34.6%) underwent this procedure. Overall, 12.3% of patients with severe symptomatic AS who are extreme surgical risk were TAVR candidates. In elderly patients undergoing SAVR, 5.2% (95% CI, 4.9-5.4%) were at high surgical risk. The study estimates that there are 292,000 high- or extreme-risk elderly patients with severe symptomatic AS in Europe and North America, representing 26,900 new TAVR candidates annually. The prevalence of intermediate- and low-risk elderly patients with severe symptomatic AS is 145,000 and 730,000, respectively.
Conclusions:
The pooled prevalence of severe AS in elderly individuals is 3.4%, and 75.6% of patients are symptomatic. Approximately 290,000 elderly patients with severe symptomatic AS and at high or extreme surgical risk are TAVR candidates in Europe and North America.
Perspective:
As this study highlights, the prevalence of AS is significant, and is projected to increase over time as our population ages. The 292,000 elderly patients who may be candidates for TAVR by existing indications include those at severe or extreme surgical risk, and the number of patients would markedly increase should TAVR be demonstrated to be clinically effective in populations at lower levels of risk. Further, this study does not include younger patients, who make up a considerable portion of TAVR candidates. Given the growing and large number of patients with severe symptomatic AS, this study highlights the need to better define which patients most benefit from TAVR. In an elderly population that commonly has multiple comorbidities, it can be challenging to determine whether symptoms are due to AS or other causes, and to identify which patients would have the largest clinical benefit. Given the sheer number of potential TAVR candidates, we need better strategies to advise our physicians on finding the best TAVR patients.
Keywords: North America, Europe
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