EXAMINING THE COST BENEFIT OF EARLY INTERVENTION FOR SEVERE AORTIC STENOSIS

AORTIC STENOSIS IS UNDERTREATED DESPITE KNOWN CLINICAL BENEFITS

The ACC/AHA Guideline mandated treatment for severe aortic stenosis (SAS) is aortic valve replacement (AVR)[1].   While over 67,000 AVRs are performed in America each year for aortic stenosis, population statistics estimate that over 500,000 people in America have severe aortic stenosis [2-4], illustrating that aortic stenosis is severely undertreated.  Early intervention with aortic valve replacement has been found to dramatically affect longevity and quality of life in severe aortic stenosis [5-7], however, a significant proportion of patients with SAS remain untreated due to a variety of reasons including perceived asymptomatic status or prohibitive comorbidities [8].  Many of these patients are indeed symptomatic and modify their lifestyles to accommodate their symptoms, and a significant proportion of them are found to have acceptable risk profiles that would permit surgical intervention with acceptable risk when they are evaluated by a surgeon[9].

 TRANSCATHETER AORTIC VALVE REPLACEMENT (TAVR) HAS INVIGORATED DISCUSSIONS ABOUT COST OF AVR

The advent of trans-catheter aortic valve replacement(TAVR) has ushered in a new era of evaluation and treatment for “high risk” and “in-operable” patients with SAS and many more patients are now being considered for aortic valve replacement.  As the population is aging, the prevalence of SAS, and consequently the utilization of AVR, and the cost of treating SAS are expected to increase dramatically.  A recent analysis of Medicare data indicated that medical management of aortic stenosis may cost the healthcare system more than $1 billion annually highlighting the poor outcomes associated with medical management of elderly patients with SAS [2, 10].  Conversely, many have questioned whether treating these patients with TAVR represents a rational use of limited societal resources considering the high cost of this technology [11-13].  Recent studies have also shown that conventional AVR (SAVR) is substantially less costly in high risk patients than TAVR [13] and data for intermediate risk patients is expected to further stratify those patients that should be treated with TAVR versus SAVR [11, 14].

EARLY INTERVENTION IN AORTIC STENOSIS HAS THE POTENTIAL TO SAVE HEALTHCARE DOLLARS IN THE LONG TERM

While the clinical benefits of AVR in patients at acceptable risk for surgery are irrefutable [6, 15], timing of intervention and significance of symptoms in the pathophysiology of disease remain vigorously debated [16].   While data is also clear that older patients with higher risk scores cost the healthcare system more no matter what kind of therapy they receive [17], very little data exists relating timing of intervention [asymptomatic  (early, little ventricular dysfunction) vs. symptomatic (late, ventricular dysfunction)] and subsequent costs as they relate to the patient’s care over the ensuing years.

 

REFERENCES

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