‘Our patients are worth it’: Tackling the undertreatment of aortic stenosis in the US

The undertreatment of aortic stenosis in the U.S. is severe, driven by deep-rooted racial and sex disparities and a disconnect between patients and their clinicians. But in a talk delivered at TVT 2019 in Chicago, one Duke physician argued it’s an issue we might be able to reverse.

It would be hard work, J. Matthew Brennan, MD, MPH, an associate professor at Duke University School of Medicine, said, considering the fact that more than 65% of people with severe symptomatic aortic stenosis (ssAS) in the U.S. remain untreated. Further, subsets of that group—including women, octogenarians and non-Hispanic blacks—are “grossly untreated,” seeing a 20% to 39% lowered likelihood of receiving the care they deserve.

Brennan said one of the biggest factors that determines a patient’s treatment path and ultimate prognosis is the cardiologist they choose. Optum data shows individuals who opt for a less aggressive physician see up to a 20% increase in one-year mortality compared to their counterparts.

“This is such a big deal that one of the biggest determinants of whether a patient actually gets treated is which cardiologist’s office they walk into,” Brennan said. “That’s as big of a determinant as their age, for example. Seems like a little problem with a terminal illness, leaving it untreated.”

But even after a patient chooses their cardiologist, Brennan said, other factors can deteriorate their care. He said the most likely culprits behind poor care involve physicians misappropriating symptoms, delaying referral and treatment, failing to adequately inform their patients of their health choices, misinterpreting echos and missing murmurs.

Studies have shown that graduate medical trainees and practicing clinicians alike are struggling to catch heart murmurs the traditional way, Brennan said, noting, “we’re just not good at using our stethoscopes anymore.” Echocardiograms are always accurate, but they’re also only as good as the experts interpreting them. In one study of echo interpretation, 48% of severe aortic valve disease diagnoses were missed by interpreting clinicians.

“That’s a problem when you’ve got a disease that progresses from mild to moderate disease to severe disease in four years,” he said. “This is not the indolent disease that we were taught about in fellowship.”

Indeed, physicians’ perception of aortic stenosis has shifted dramatically over time. The system in place to treat ssAS patients today was designed for a disease process that was only treatable with surgical interventions—a far cry from protocol today, where TAVR patients might qualify for discharge within a day of their procedure.

Brennan said that moving forward it will be important to address referral and treatment delays, which are common. Around a quarter of patients in one study waited at least five weeks from referral to treatment for their stenosis, which translated to an 8% increased risk in mortality. Another 17% of patients referred for treatment never actually received it.

According to Brennan, the ideal next step would be to implement systematic follow-up of patients with aortic stenosis in each of the country’s health systems. He admitted it’s not something that happens in his own system at Duke, suspecting the situation is similar at most centers across the U.S.

“That can’t happen in today’s world,” he said. “We need to be following these patients better.”

He also suggested emphasizing objective treatment criteria over subjective symptoms, creating better tools for patient education and better training for providers, and refining technologies and techniques in the space.

“We’ve got a ways to go,” Brennan said. “This is a system that needs reforming, but our patients are worth it.”