The value of evaluating cardiac damage in patients with aortic stenosis: a systematic review and meta-analysis.

BACKGROUND: Aortic stenosis (AS) is a common valvular heart disease where aortic valve replacement (AVR) is the only treatment. A novel staging system based on cardiac damage was developed to assess the pathophysiological consequence of AS and this has been shown to be associated with outcomes post AVR. METHODS: We conducted a systematic review of studies which evaluated cardiac damage in patients with AS. A search of MEDLINE and EMBASE was performed with data being extracted from relevant studies. The main outcome of interest were proportion of AS patients with signs of cardiac damage, all-cause mortality, cardiovascular mortality, and major adverse cardiovascular events. RESULTS: A total of 18 studies were included with 21,876 patients (mean age 79 years, 52.7% males). Pooled analysis indicated 76% of symptomatic severe AS patients and 88% of asymptomatic moderate/severe AS patients had signs of cardiac damage, with stage two being the most commonly reported (25.1% and 32.3% respectively). For symptomatic severe AS patients, the pooled all-cause mortality and cardiovascular mortality rates increased along an increase in cardiac damage stage from 9.4% to 2.0% respectively for stage 0 to 24.2% and 36.1% respectively for stage 4. In patients with asymptomatic moderate / severe AS, all-cause mortality ranged from 30.0% in stage 0 to 51.2% in stage 3/4. In patients with symptomatic severe AS undergoing AVR, meta-analysis indicated an increase in odds of cardiovascular related mortality for stage 4 cardiac damage only (OR 6.89, 95% CI: 3.04,15.61, p = 0.003). An increased odds of all-cause mortality was seen in for cardiac damage stages 1, 3 and 4 (OR 1.4, 95%CI: 1.10,1.77, p = 0.01, OR 2.27, 95%CI: 1.76,2.92, p = 0.0002 and OR 2.94, 95%CI: 1.97,4.38, p = 0.0006 respectively). CONCLUSIONS: Cardiac damage is a common finding amongst patients with AS irrespective of AS severity or symptomatic status. Mortality rates appear to increase alongside an increase in cardiac damage staging. Cardiac damage may provide prognostic valve when considering the timing of AVR with left ventricular and right ventricular abnormalities being associated with increased odds of mortality. CLINICAL TRIAL NUMBER: Not applicable.