Cardiology, Norfolk and Norwich University Hospital, Norwich, UK
Norwich Medical School, University of East Anglia, Norwich, UK.
Open Heart. 2022 May;9(1). doi: 10.1136/openhrt-2022-001982.
The management of severe aortic stenosis mandates consideration of aortic valve intervention for symptomatic patients. However, for asymptomatic patients with severe aortic stenosis, recent randomised trials supported earlier intervention. We conducted a systematic review and meta-analysis to evaluate all the available data comparing the two management strategies.
PubMed, Cochrane and Web of Science databases were systematically searched from inception until 10 January 2022. The search key terms were 'asymptomatic', 'severe aortic stenosis' and 'intervention'.
Meta-analysis of two published randomised trials, AVATAR and RECOVERY, included 302 patients and showed that early intervention resulted in 55% reduction in all-cause mortality (HR=0.45, 95% CI 0.24 to 0.86; I 0%) and 79% reduction in risk of hospitalisation for heart failure (HR=0.21, 95% CI 0.05 to 0.96; I 15%). There was no difference in risk of cardiovascular death between the two groups (HR=0.36, 95% CI 0.03 to 3.78; I 78%). Additionally, meta-analysis of eight observational studies showed improved mortality in patients treated with early intervention (HR=0.38, 95% CI 0.26 to 0.56; I 77%).
This meta-analysis provides evidence that, in patients with severe asymptomatic aortic stenosis, early intervention reduces all-cause mortality and improves outcomes compared with conservative management. While this is very encouraging, further randomised controlled studies are needed to draw firm conclusions and identify the optimal timing of intervention.
CRD42022301037.
严重主动脉瓣狭窄的管理需要考虑对有症状的患者进行主动脉瓣干预。然而，对于无症状的严重主动脉瓣狭窄患者，最近的随机试验支持更早的干预。我们进行了系统评价和荟萃分析，以评估比较两种管理策略的所有可用数据。
从建库到 2022 年 1 月 10 日，系统地检索了 PubMed、Cochrane 和 Web of Science 数据库。检索的关键词是“无症状”、“严重主动脉瓣狭窄”和“干预”。
对两项已发表的随机试验 AVATAR 和 RECOVERY 的荟萃分析纳入了 302 例患者，结果表明早期干预可使全因死亡率降低 55%（HR=0.45，95%CI 0.24 至 0.86；I 0%），心力衰竭住院风险降低 79%（HR=0.21，95%CI 0.05 至 0.96；I 15%）。两组心血管死亡率无差异（HR=0.36，95%CI 0.03 至 3.78；I 78%）。此外，对八项观察性研究的荟萃分析表明，早期干预可改善患者的死亡率（HR=0.38，95%CI 0.26 至 0.56；I 77%）。
这项荟萃分析提供了证据，表明在严重无症状主动脉瓣狭窄患者中，与保守治疗相比，早期干预可降低全因死亡率并改善预后。虽然这非常令人鼓舞，但仍需要进一步的随机对照研究来得出明确的结论并确定最佳干预时机。
PROSPERO 注册号：CRD42022301037。
