Treatment disparities and prognostic implications in octogenarians versus non-octogenarians with high-gradient severe aortic stenosis.

Background: Aortic valve replacement (AVR) is considered one of the most potent disease-modifying procedures among patients with severe aortic stenosis (sAS). Accordingly, we have witnessed a consistent increase in the procedure rates in recent years. Nevertheless, the elderly population, particularly octogenarians, remains relatively undertreated. The current study aims to document the disparities in AVR rates among octogenarians and its prognostic significance.

Methods: A vast database of Maccabi Health Services, the second largest health maintenance organisation in Israel, counting nearly 2.8 million members, was retrospectively analysed from 2005 to 2021 for all patients over 60 years, with a detailed echocardiography report compatible with a diagnosis of high-gradient sAS. The database was extracted using the MDClone healthcare data platform, generating synthetic data reliably representing the original population. All-cause mortality was set to be the primary outcome, and survival models using adjusted multivariable analyses for several clinical and echocardiographic parameters were applied.

Results: The cohort consisted of 1396 patients with high-gradient sAS (76±7 years) with 39% octogenarians. Octogenarians were less likely to undergo AVR (42% vs 60%, p<0.01) and presented more severe clinical profiles. AVR significantly reduced mortality and hospitalisations in both age groups, but octogenarians showed a pronounced survival benefit regardless of symptom status. A time-dependent analysis showed that AVR was associated with reduced all-cause mortality (HR 0.30, 95% CI 0.23 to 0.41, p<0.001) within the octogenarian group in 5 years. A similar protective effect was shown in the non-octogenarian group (HR 0.32, 95% CI 0.22 to 0.46, p<0.001).

Conclusion: This study highlights significant treatment disparities in AVR among octogenarians with high-gradient sAS despite clear benefits in survival and reduced hospitalisations. The findings suggest the need for more inclusive treatment strategies, particularly for older patients, and underscore the importance of AVR in improving clinical outcomes in this population.