Vakilpour Azin, Levin Michael G, Anyanwu Emeka C, Denduluri Srinivas, Ravindra Krishna, Boakye Ellen, Duqueney Estherland, Cutts Jamey A, Giffin Liam C, Weber Ian K, Lee Jennifer N, Adusumalli Srinath, Lopez-Mattei Juan, Chittams Jesse, Jones David B, Weiss Kathleen, Hartwell Carlton, Bolooki Michael, Bourque Jamieson M, Scherrer-Crosbie Marielle
Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA.
Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA; Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA.
Am Heart J. 2025 Dec;290:347-358. doi: 10.1016/j.ahj.2025.07.014. Epub 2025 Jul 22.
Patients with severe aortic stenosis (AS) require timely follow-up by cardiac specialists and aortic valve replacement (AVR). This multicenter study evaluates how the specialty of the provider who ordered the initial echocardiogram influences these endpoints.
Patients from 3 health systems with a first echocardiogram (index echo) diagnosing severe AS from Jan 1, 2019 to Dec 31, 2022, were categorized based on the specialty of the provider ordering the echo. Endpoints included a composite outcome of early cardiac follow-up or AVR (within 90 days), AVR during follow-up, and mortality. Logistic regression and Cox proportional hazard models were used to identify factors associated with the endpoints.
4,249 patients (77 years; 58% male; 88% white; 72% symptomatic AS) were followed for a median of 552 days. Eighty-nine percent of patients achieved the composite outcome, yet 1,801 patients (42%) did not receive an AVR during the follow-up period, including 32% of symptomatic patients. Patients referred for the index echo by noncardiac specialty providers had lower rates of early cardiac follow-up or AVR (adjusted OR: 0.33, 95% CI, 0.25-0.43), lower AVR rates (adjusted HR: 0.59, 95% CI, 0.53-0.66), and higher mortality (adjusted HR: 1.65; 95% CI, 1.44-1.90) compared to the patients referred by a cardiology provider; the discrepancy was more pronounced in patients with low-flow, low-gradient AS.
In this large multicenter study of patients with severe AS, patients with a noncardiac specialty provider were less likely to receive timely cardiac follow-up and AVR, and had higher mortality. Initiatives to address disparities in care and improve outcomes for this high-risk population are needed.
重度主动脉瓣狭窄（AS）患者需要心脏专科医生及时随访并进行主动脉瓣置换术（AVR）。这项多中心研究评估了开具初始超声心动图检查的医生专业如何影响这些终点。
对2019年1月1日至2022年12月31日期间来自3个医疗系统、首次超声心动图（索引超声）诊断为重度AS的患者，根据开具超声检查的医生专业进行分类。终点包括早期心脏随访或AVR（90天内）、随访期间的AVR以及死亡率的复合结局。采用逻辑回归和Cox比例风险模型来确定与终点相关的因素。
4249例患者（年龄77岁；58%为男性；88%为白人；72%为有症状的AS）的中位随访时间为552天。89%的患者达到了复合结局，但1801例患者（42%）在随访期间未接受AVR，其中有症状患者占32%。与由心脏病专科医生转诊的患者相比，由非心脏专科医生转诊进行索引超声检查的患者早期心脏随访或AVR的发生率较低（调整后的OR：0.33，95%CI，0.25 - 0.43），AVR发生率较低（调整后的HR：0.59，95%CI，0.53 - 0.66），死亡率较高（调整后的HR：1.65；95%CI，1.44 - 1.90）；在低流量、低梯度AS患者中差异更为明显。
在这项针对重度AS患者的大型多中心研究中，由非心脏专科医生转诊的患者接受及时心脏随访和AVR的可能性较小，且死亡率较高。需要采取措施解决护理差异并改善这一高危人群的结局。
