Mitsuru Ishii1, Tomohiko Taniguchi2, Takeshi Morimoto3, Hisashi Ogawa1, Nobutoyo Masunaga1, Mitsuru Abe1, Yusuke Yoshikawa2, Hiroki Shiomi2, Kenji Ando4, Norio Kanamori5, Koichiro Murata6, Takeshi Kitai7, Yuichi Kawase8, Chisato Izumi9, Makoto Miyake9, Hirokazu Mitsuoka10, Masashi Kato11, Yutaka Hirano12, Shintaro Matsuda2, Kazuya Nagao13, Tsukasa Inada13, Hiroshi Mabuchi14, Yasuyo Takeuchi15, Keiichiro Yamane16, Mamoru Toyofuku17, Eri Minamino-Muta2, Takao Kato2, Moriaki Inoko18, Tomoyuki Ikeda19, Akihiro Komasa20, Katsuhisa Ishii20, Kozo Hotta21, Nobuya Higashitani22, Yoshihiro Kato23, Yasutaka Inuzuka24, Toshikazu Jinnai22, Yuko Morikami25, Masaharu Akao1, Kenji Minatoya26, Takeshi Kimura2. 1. Department of Cardiology, National Hospital Organization Kyoto Medical Center. 2. Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine. 3. Department of Clinical Epidemiology, Hyogo College of Medicine. 4. Department of Cardiology, Kokura Memorial Hospital. 5. Division of Cardiology, Shimada Municipal Hospital. 6. Department of Cardiology, Shizuoka City Shizuoka Hospital. 7. Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital. 8. Department of Cardiovascular Medicine, Kurashiki Central Hospital. 9. Department of Cardiology, Tenri Hospital. 10. Division of Cardiology, Nara Hospital, Kinki University Faculty of Medicine. 11. Department of Cardiology, Mitsubishi Kyoto Hospital. 12. Department of Cardiology, Kindai University Hospital. 13. Department of Cardiovascular Center, Osaka Red Cross Hospital. 14. Department of Cardiology, Koto Memorial Hospital. 15. Department of Cardiology, Shizuoka General Hospital. 16. Department of Cardiology, Nishikobe Medical Center. 17. Department of Cardiology, Japanese Red Cross Wakayama Medical Center. 18. Cardiovascular Center, The Tazuke Kofukai Medical Research Institute, Kitano Hospital. 19. Department of Cardiology, Hikone Municipal Hospital. 20. Department of Cardiology, Kansai Electric Power Hospital. 21. Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center. 22. Department of Cardiology, Japanese Red Cross Otsu Hospital. 23. Department of Cardiology, Saiseikai Noe Hospital. 24. Department of Cardiology, Shiga Medical Center for Adults. 25. Department of Cardiology, Hirakata Kohsai Hospital. 26. Department of Cardiovascular Surgery, Kyoto University Graduate School of Medicine.
Abstract
BACKGROUND: There has not been a previous report on the long-term outcomes of those patients who refuse aortic valve replacement (AVR) despite physicians' recommendations.Methods and Results: Among 3,815 consecutive patients with severe aortic stenosis (AS) enrolled in the CURRENT AS registry, the study population comprised 2,005 symptomatic patients, who were subdivided into 3 groups by their treatment strategy and the reasons for conservative strategy (Initial AVR group: n=905; Patient rejection group: n=256; Physician judgment group, n=844). The primary outcome measure was a composite of aortic valve-related death and heart failure hospitalization. Patients in the patient rejection group as compared with those in the physician judgment group were younger, and had less comorbidities, and lower surgical risk scores. The cumulative 5-year incidence of the primary outcome measure in the patient rejection group was markedly higher than that in the initial AVR group, and was similar to that in the physician judgment group (60.7%, 19.0%, and 66.4%, respectively). CONCLUSIONS: Patient rejection was the reason for non-referral to AVR in nearly one-quarter of the symptomatic patients with severe AS who were managed conservatively. The dismal outcome in patients who refused AVR was similar to that in patients who were not referred to AVR based on physician judgment despite less comorbidities and lower surgical risk scores in the former than in the latter.
BACKGROUND: There has not been a previous report on the long-term outcomes of those patients who refuse aortic valve replacement (AVR) despite physicians' recommendations.Methods and Results: Among 3,815 consecutive patients with severe aortic stenosis (AS) enrolled in the CURRENT AS registry, the study population comprised 2,005 symptomatic patients, who were subdivided into 3 groups by their treatment strategy and the reasons for conservative strategy (Initial AVR group: n=905; Patient rejection group: n=256; Physician judgment group, n=844). The primary outcome measure was a composite of aortic valve-related death and heart failure hospitalization. Patients in the patient rejection group as compared with those in the physician judgment group were younger, and had less comorbidities, and lower surgical risk scores. The cumulative 5-year incidence of the primary outcome measure in the patient rejection group was markedly higher than that in the initial AVR group, and was similar to that in the physician judgment group (60.7%, 19.0%, and 66.4%, respectively). CONCLUSIONS:Patient rejection was the reason for non-referral to AVR in nearly one-quarter of the symptomatic patients with severe AS who were managed conservatively. The dismal outcome in patients who refused AVR was similar to that in patients who were not referred to AVR based on physician judgment despite less comorbidities and lower surgical risk scores in the former than in the latter.