The Evolving Management of Aortic Valve Disease: 5-Year Trends in SAVR, TAVR, and Medical Therapy

https://doi.org/10.1016/j.amjcard.2019.05.044Get rights and content

Aortic stenosis (AS) and regurgitation (AR) may be treated with surgical aortic valve replacement (SAVR), transcatheter AVR (TAVR), or medical therapy (MT). Data are lacking regarding the usage of SAVR, TAVR, and MT for patients hospitalized with aortic valve disease and the characteristics of the patients and hospitals associated with each therapy. From the Nationwide Readmissions Database, we determined utilization trends for SAVR, TAVR, and MT in patients with aortic valve disease admitted from 2012 to 2016 for valve replacement, heart failure, unstable angina, non–ST-elevation myocardial infarction, or syncope. We also performed multinomial logistic regressions to investigate associations between patient and hospital characteristics and treatment. Among 366,909 patients hospitalized for aortic valve disease, there was a 48.1% annual increase from 2012 through 2016. Overall, 19.9%, 6.7%, and 73.4% of patients received SAVR, TAVR, and MT, respectively. SAVR decreased from 21.9% in 2012 to 18.5% in 2016, whereas TAVR increased from 2.6% to 12.5%, and MT decreased from 75.5% to 69.0%. Older age, female sex, greater severity of illness, more admission diagnoses, not-for-profit hospitals, large hospitals, and urban teaching hospitals were associated with greater use of TAVR. In multivariable analysis, likelihood of TAVR relative to SAVR increased 4.57-fold (95% confidence interval 4.21 to 4.97). TAVR has increased at the expense of both SAVR and MT, a novel finding. However, this increase in TAVR was distributed inequitably, with certain patients more likely to receive TAVR certain hospitals more likely to provide TAVR. With the expected expansion of indications, inequitable access to TAVR must be addressed.

Section snippets

Methods

Data were obtained from the Nationwide Readmissions Database (NRD), the largest, all-payer inpatient care database of the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project (HCUP) containing an approximately 20% stratified sample of discharges from all hospitals in 27 US states.12 Data from the NRD and its sister database, the National Inpatient Sample (NIS), have been used for multiple previous studies evaluating patients who have undergone TAVR.13, 14, 15, 16

Results

The sample population included 366,909 patients with IA discharges for aortic valve disease and one of the following procedures or diagnoses: SAVR (n = 64,695), TAVR (n = 18,107), CHF (n = 276,955), UA (n = 11,074), NSTEMI (n = 47,749), or syncope (n = 21,858).

The average age was 77.8 years, and 48.7% of the study population was female. Fifty-eight percent (57.9%) of patients had major or extreme loss of function due to severity of illness, and 53.0% of patients had major or extreme likelihood

Discussion

In a large, nationally-representative sample, the number of patients hospitalized for aortic valve disease increased 48.1% from 2012 through 2016. The likelihood of receiving TAVR increased with a RRR of 4.57 relative to SAVR and 4.41 relative to MT, a novel finding. However, not all patients and hospitals absorbed TAVR equally: increasing age, female sex, severity of illness rating, high number of diagnoses, not-for-profit hospital ownership, large hospital size, and teaching hospital status

Conclusions

From 2012 through 2016, the use of TAVR increased at the expense of both SAVR and MT. The greatest use of TAVR was associated with patients at elevated surgical risk and hospitals that were large, not-for-profit, and urban teaching hospitals. Expected expansion of TAVR indications portends continued growth of TAVR and reduction in SAVR and MT. The inequitable distribution of TAVR therapy must be addressed.

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