Treatment Patterns, Disparities, and Management Strategies Impact Clinical Outcomes in Patients with Symptomatic Severe Aortic Regurgitation

Background Symptomatic severe aortic regurgitation (ssAR) is a Class I recommendation for surgical aortic valve replacement (SAVR). We sought to evaluate the practice patterns and drivers of ssAR patients receiving SAVR treatment. Methods Using a US dataset of de-identified electronic health records, we identified integrated delivery network patients diagnosed with ssAR between 2008 and 2016 with >= 2 symptom-related notes (heart failure, angina, dyspnea, pre-syncope, or syncope) within six months prior to diagnosis. Results From a final cohort of 4,608 ssAR patients, 25.7% of ssAR patients underwent SAVR within 1 year of diagnosis; mortality at 1 year was 9% after SAVR, and 24% for those untreated. Using multilevel, multivariable, cause-specific models, women and patients >80 years old were found to be treated significantly less likely [hazard ratios (HR) 0.79 (95% confidence interval [CI]: 0.69-0.90) and 0.28 (0.22-0.37), respectively]. Patients with concomitant moderate/severe aortic stenosis [1.70 (1.43-2.03)], bicuspid aortic valve disease [1.33 (1.13-1.56)], and endocarditis [2.70 (1.04-3.57)] were more likely to be treated. Using multivariable Cox proportional hazard models, ssAR patients managed by cardiologists in the highest SAVR treatment rate tertile had a 23% lower risk of 1-year mortality compared to patients managed by cardiologists in the lowest SAVR treatment rate tertile [0.77 (0.60-0.98)]. Conclusions We identified significant disparities in the treatment of ssAR patients, specifically women, older patients, and patients managed by cardiologists with a lower SAVR treatment rate. These gaps should be addressed to level the quality of care delivered to all ssAR patients.