Socioeconomic status and mental health make a big impact on AVR outcomes
![Large peridevice leaks after left atrial appendage occlusion (LAAO) are incredibly rare and not associated with a greater risk of adverse outcomes, according to new research published in JACC: Clinical Electrophysiology.[1] Smaller residual links are more common, however, and associated with a risk of thromboembolic and bleeding events.](/sites/default/files/styles/top_stories/public/2018-08/olderpatient-doctor.jpg.webp?itok=Cv18wcDr)
Psychosocial risk factors (PSRFs) such as dementia, post-traumatic stress disorder (PTSD) and low socioeconomic status are associated with worse outcomes among patients undergoing transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR), according to new data published in JACC: Cardiovascular Interventions.[1] The link appears to be especially strong among SAVR patients.
“Over the last decade, there has been increasing interest in socioeconomic factors and their role in healthcare disparities in both cardiovascular disease and cardiothoracic surgery,” said first author Paige Newell, MD, a specialist with the division of cardiac surgery at Brigham and Women’s Hospital, and colleagues. “However, a critical factor that remains under-recognized is a patient’s degree of social support and the presence of PSRFs. Increased PSRFs have been associated with worse prognosis and increased risk of cardiovascular mortality. However, despite this evidence that PSRFs are important risk factors for adverse perioperative outcomes, they remain under-recognized and understudied in the treatment of valvular heart disease.”
Newell et al. examined data from more than 160,000 adult patients who underwent TAVR or SAVR in the United States from 2016 to 2018. All data came from the National Readmission Database.
These are the PSRFs the team focused on for its analysis:
- Limited cognitive understanding (intellectual disabilities, dementia)
- Substance use (current or prior tobacco use, current or prior alcohol-, opioid- or cocaine-related disorders)
- Psychiatric disease (Major depressive orders, obsessive compulsive disorder, agoraphobia, social phobia, anxiety disorders, bipolar disorder, schizophrenia, schizoaffective disorder, PTSD)
- Low socioeconomic status, based on the median household income of the patient’s zip code
- Uninsured
More than 87,000 patients included in the study underwent TAVR, and more than 74,000 patients underwent SAVR. While 54.9% of SAVR patients presented with no PSRFs, low socioeconomic status (22.7%) and psychiatric diseases (18.1%) were the most common. Also, 63.6% of TAVR patients presented with no PSRFs, and low socioeconomic status (19.9%) and psychiatric diseases (13.2%) were the most common among that group.
The researchers explored both groups, noting that SAVR patients with PSRFs were “significantly younger,” more likely to be a woman and more likely to have a nonelective hospital admission. TAVR patients with PSRFs were also significantly younger, more likely to be a woman and more likely to have a nonelective hospital admission.
In-hospital mortality rates and 30-day composite morbidity rates were the same for SAVR and TAVR patients with and without PSFRs. Mortality after 30 days was actually notably higher for SAVR patients with at least one PSRF, but this was not true for the TAVR group.
Patients with PSRFs were more likely to be readmitted after 30 days—and they were also more likely to be readmitted after 90 days or 180 days. This was true for the SAVR patients and the TAVR patients.
“Together these findings suggest that PSRFs are important nontraditional risk factors that contribute to socioeconomic disparities and worse postoperative outcomes but are under-recognized when evaluating patients with aortic valve disease,” the authors wrote.
The group also noted that, based on these findings, some patients with PSRFs may be a better fit for TAVR than SAVR due to “its faster and less intensive recovery period,” but more research is still needed.
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.