Underdiagnosed and undertreated: How cardiologists and primary care physicians are working together to identify patients with severe aortic stenosis
Aortic stenosis (AS) is one of the most common—and growing—cardiac conditions. In particular, the prevalence of severe AS rises markedly among elderly Americans, affecting an estimated 3.4% of Americans 75 and older.[1]
Jayendrakumar (Jay) Patel, MD, a structural interventional cardiologist with Clearwater Cardiovascular Consultants, believes up to 50% of the country’s severe AS patients have yet to be recognized. This massive underdiagnosis, he says, is largely due to patients—and the physicians who treat them—failing to recognize certain symptoms.
One of the largest issues, according to Patel, is that symptoms often develop in a gradual and subtle manner. Patients may fail to realize that they are experiencing any of the symptoms most commonly associated with AS—shortness of breath, dizziness, fatigue. A deeper dive, including more pointed questions and imaging exams when necessary, can better spotlight the issue.
Fortunately, Patel notes, there are a number of things providers can do to tackle this issue head-on and better identify AS. It just takes care, communication and a healthy dose of persistence.
“It’s really important that we, as cardiologists, make sure we form strong relationships with our primary care physician colleagues (PCPs),” he says. “Communication and education are essential for these patients to get the treatment they need.”
“Maybe a patient gets tired more quickly than normal at the end of the day or is no longer able to mow the lawn without getting short of breath. These might seem like normal things that happen as you get older—and sometimes they are—but in reality, they may be warning signs that suggest the patient is suffering from AS.”
- Akira Wada, MD, Cardiologist, OhioHealth Physician Group Heart and Vascular
Asymptomatic or simply inactive?
Akira Wada, MD, a cardiologist with OhioHealth Physician Group Heart and Vascular, says he regularly sees patients ignore or dismiss symptoms because they believe they’re just a common side effect of the aging process.
“Maybe a patient gets tired more quickly than normal at the end of the day or is no longer able to mow the lawn without getting short of breath,” he says. “These might seem like normal things that happen as you get older—and sometimes they are—but in reality, they may be warning signs that suggest the patient is suffering from AS.”
Another significant challenge is patients who appear to be asymptomatic because they’re going out of their way to avoid triggering symptoms. If going to the grocery store suddenly causes them to be short of breath, for example, the patient just stops going to the grocery store. Or if using stairs starts to cause considerable issues, the patient adapts by taking the elevator and escalator instead.
“These patients might technically be asymptomatic because they are so inactive—but that does not suggest they are actually asymptomatic as we understand the word today,” Wada says.
The inactivity seen in so many older patients is why Patel encourages everyone he treats to exercise at least three times per week. He recommends taking 20- or 30-minute walks a few times a week or even getting in a pool and moving around for a bit.
“It needs to be something they enjoy enough to keep doing it as recommended,” Patel says. “If that means dancing around the house for 30 minutes because it’s the one thing the patient truly loves, that works for me. As long as they’re staying active.”
This is the same reason, he notes, that so many cardiovascular specialists turn to exercise testing when attempting to diagnose seemingly asymptomatic severe AS. It challenges patients to see if they can truly be active without showing any symptoms—all from the comfort of a safe, controlled environment. Monitoring a person’s blood pressure and heart rate during exercise tests provides physicians with the ideal opportunity to track how the body reacts when presented with good movement.
The power of education
Before cardiologists even see patients, the continuum of care typically begins with a PCP. Making sure PCPs know all the ways patients mentally minimize their symptoms and try to pass them off as part of the aging process can go a long way toward ensuring they still receive a thorough evaluation.
“I’m not throwing PCPs under the bus here,” Wada says. “They do a great job. But this is an underdiagnosed condition that is only going to grow more and more common as baby boomers continue to age. There just needs to be more awareness, and that’s something we can help with by talking to our PCPs and letting them know what to look out for.”
Helping PCPs know what kind of questions they should ask is absolutely crucial, he adds.
PCPs also should know a full list of symptoms to watch for. Shortness of breath and a limited exercise capacity might be some of the most common signs of AS, but lightheadedness, dizziness, swelling in the legs, chest pain and low energy levels are other things that should be on a PCP’s radar whenever treating an older patient who could potentially show signs of severe AS.
PCPs, when they can, should spark conversation with the patient’s family members and friends who come along for office visits. Loved ones can have a much better perspective than the patients themselves when it comes to gradual changes in health.
“A daughter might come in with her mother and say, ‘I’ve noticed mom isn’t as active as she used to be,” Wada says. “That kind of insight is incredibly valuable as a PCP is trying to make their initial diagnosis. Patients are so quick to minimize a problem—bringing in their loved ones can even that playing field a bit and help paint a more accurate picture of the situation.”
“Many patients will show up at the doctor scared of treatment, causing them to keep certain details from their physician. That’s one of the biggest reasons AS remains so underdiagnosed right now—that fear patients carry with them.”
- Jayendrakumar (Jay) Patel, MD, Structural Interventional Cardiologist, Clearwater Cardiovascular Consultants
Patients, of course, also need to be properly educated.
Patel, for instance, says many PCPs he works with now have a one-page document they can give patients that lists out potential AS symptoms. The document also includes a detailed, but easy-to-understand definition of AS, providing patients a helpful reference to hang on the refrigerator or near a telephone.
Educating a patient also can help limit any uneasiness or fear they may be experiencing.
“Many patients will show up at the doctor scared of treatment, causing them to keep certain details from their physician,” Patel says. “That’s one of the biggest reasons AS remains so underdiagnosed right now—that fear patients carry with them.”
The more PCPs talk to these patients and form a strong relationship with them, the more likely it is that the patient will be honest and direct.
What happens next?
Once AS has potentially been identified, the clinical decision-making process really begins. Wada, who specializes in advanced cardiac imaging, says echocardiograms are typically the first test for patients with suspected AS. If the results show nothing to be concerned about, the patient might just be scheduled for a repeat in another six or 12 months.
MRI scans are another option, especially in instances when the patient is clearly symptomatic, but echocardiography is indeterminate. CT scans can be helpful, Wada notes, if the aortic valve calcium scores are elevated. If AS is confirmed, cardiac catheterization also may come into play.
In late 2020, the American College of Cardiology (ACC) and American Heart Association (AHA) released updated valvular heart disease (VHD) guidelines that cover this topic, and many others, in great detail. The 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease was published in both the Journal of the American College of Cardiology and Circulation, providing clinicians with the latest research and evidence related to identifying, diagnosing, treating and managing VHD.
The ACC/AHA guidance separates patients into Stage A (individuals at risk of AS), Stage B (individuals with progressive hemodynamic obstruction), Stage C (individuals with severe asymptomatic AS) and Stage D (individuals with symptomatic AS), noting that “the inherent variability of the measurements and calculations should always be considered in clinical decision-making.”
The guidelines also focus on a transcatheter aortic valve replacement (TAVR) that offers the biggest shift in AS treatment in the last decade, offering a minimally invasive therapy for severe AS patients and improving overall quality of life.
While TAVR was initially reserved for only high-risk patients, studies show it’s a safe and effective treatment option for low-risk AS patients as well.
“TAVR has completely changed the paradigm of how we approach treating patients with severe AS,” Patel says. “It is safe, the risk of complications is low and it can improve the patient’s quality of life.”
As TAVR continues to gain momentum throughout the world, healthcare providers now have more tools for combatting AS than ever before. If cardiologists can continue to work closely with PCPs, educating them on the latest guidelines and helping them improve patient care, it should lead to a massive step forward for the quality of cardiovascular care all over the world.
“We must continue to work together,” Patel says. “Communicate, communicate, communicate. Communication and patient education are key as we work to provide the best possible care to these patients.”
Michael has more than 18 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.