Women With Moderate or Severe Aortic Stenosis by Aortic Valve Area Are Disproportionately Classified With Normal-Flow Low-Gradient Aortic Stenosis and Assigned Lower Severity Grades Than Men

Purpose

Patients with aortic stenosis (AS) may have discordant severity grades between AS by aortic valve area (AS_AVA) and AS using hemodynamic-based guidelines (AS_GL). Individuals with normal left ventricular function and normal-flow low-gradient (NF-LG) AS that is moderate or severe by AVA are downgraded in severity by current guidelines. We evaluated the prevalence and risk of NF-LG AS in patients with moderate or severe AS_AVA.

Methods

We compared the prevalence and mortality of NF-LG AS and low-flow low-gradient (LF-LG) AS compared to normal-flow high-gradient (NF-HG) AS in patients with moderate and severe AS_AVA and normal left ventricular function.

Results

Among 5360 patients, 2974 had moderate AS_AVA and 2386 had severe AS_AVA (mean age 73.3 ± 12.8 years; 49.3% female; 1637 deaths over median of 4.2 years). In moderate AS_AVA, women were more frequently classified as NF-LG AS, with AS severity downgraded to mild using guidelines (52.0% women vs. 29.1% men, p < 0.001). In severe AS_AVA, women were also more likely to have NF-LG AS and be classified as mild or moderate AS using guidelines (23.9% women vs. 14.4% men, p < 0.001). Patients with NF-LG moderate or severe AS_AVA had comparable mortality to NF-HG AS (p > 0.05 for each).

Conclusion

Women with moderate or severe AS_AVA have markedly higher rates of NF-LG AS than men and are more likely to be assigned a lower AS severity grade based on current guidelines, despite mortality similar to NF-HG AS. Discordance in AS severity between AS_AVA and AS_GL is common in both genders, although more common in women.