Heart failure before and after TAVR: New data point to ongoing concerns
A majority of transcatheter aortic valve replacement (TAVR) present with a history of heart failure (HF). According to new data published in the Journal of Cardiovascular Medicine, however, many of those patients are not being given the HF medications they need after undergoing TAVR.
“Cardiovascular morbidity and mortality remain high after TAVR,” wrote first author Elena Surkova, MD, MSc, PhD, a senior medical director at AstraZeneca and consultant cardiologist with Royal Brompton and Harefield Hospitals, and colleagues. “There is a lack of detailed data on the prevalence of HF in patients undergoing TAVR, medication prescription rates, including the main pillars of HF standard of care, and predictors of HF worsening following the procedure.”
Surkova et al. examined data from more than 37,000 U.S. patients who underwent TAVR from 2017 to 2023. The mean age was 80 years old, and 44.7% of patients were women.
A HF diagnosis was recorded in 56.9% of patients within a year of undergoing TAVR and 70.4% of patients when they presented at the hospital for TAVR. In addition, 18.6% of patients had acute HF episodes within a year of undergoing TAVR. When exploring other comorbidities besides HF, the group noted that 50.3% of patients had a history of type 2 diabetes, 37.9% had a history of atrial fibrillation, 9.6% had a history of myocardial infarction and 56.6% had a history of chronic kidney disease.
The researchers also found that medication prescriptions changed a relatively small amount following TAVR. In the year before TAVR, for example, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEis/ARBs) were prescribed in 45.9% and 46.4% of patients, respectively. Those percentages for other medications were 49% and 54% for beta-blockers, 34% and 40.3% for loop diuretics, 6.1% and 8.4% for mineralocorticoid receptor antagonists (MRAs) and 2.1% and 3.4% for sodium-glucose contransporter-2 inhibitors (SGLT2is).
Surkova and colleagues also spent some time calculating patient risks following TAVR. After one year, HF hospitalizations and all-cause mortality occurred in 8.8% and 9.8% of patients, respectively. After two years, HF hospitalizations and all-cause mortality occurred in 13.8% and 17.9% of patients, respectively. A prior HF diagnosis, multiple prior acute HF exacerbations, atrial fibrillation or atrial flutter, chronic kidney disease and type 2 diabetes were all identified as key predictors of a HF hospitalization following TAVR.
“While the low prescription rates of SGLT2is observed in our cohort should be interpreted within the temporal context of our study period, the suboptimal prescription rates for established therapies (MRAs, ACEis/ARBs, beta-blockers) reflect the lack of established clinical recommendations on medical therapy in patients with severe aortic stenosis before and after correction, and this indicates a clear need for evidence generation to support more intense medical management of HF in this patient population.,” the authors wrote.
The group also pointed to the “significant residual risk of HF hospitalization and/or mortality” after TAVR as an ongoing issue that has not yet been properly addressed.
“Our findings highlight the underutilization of evidence-based HF therapies and support the need for future clinical trials investigating the role of medical management of underlying HF and other key comorbidities to decrease the burden of HF admissions and mortality after TAVR,” the group concluded.
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Michael has more than 19 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.