Aortic stenosis: Do health disparities affect treatment?

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Aortic stenosis is the narrowing of the hard-working aortic valve in your heart. Think of the aortic valve as a door — constantly opening and shutting — through which oxygenated blood is pumped out to the body. The narrowing of this valve can lead to heart failure over time if […]

Aortic stenosis is the narrowing of the hard-working aortic valve in your heart. Think of the aortic valve as a door — constantly opening and shutting — through which oxygenated blood is pumped out to the body. The narrowing of this valve can lead to heart failure over time if the problem isn’t identified and corrected by a heart specialist. And unfortunately, research shows that access to proper diagnosis and care for this condition lags for several groups, including African Americans and people of lower income.

Understanding aortic stenosis and learning how it is identified and treated can help you get good care — and possibly extend your life.

What is aortic stenosis?

The heart has two pumping chambers known as ventricles. The main pump of the heart is the left ventricle. As your heart beats, its muscles contract, ejecting the oxygenated blood collected within the left ventricle through the open door of the aortic valve, and out into your body through a major artery called the aorta.

Heart valves may have trouble opening (stenosis), closing (regurgitation or insufficiency), or both. In aortic stenosis, the aortic valve fails to open fully. This causes turbulence in blood flowing through the valve, which is noticeable as a heart murmur. It also creates excessive pressure inside the left ventricle, eventually leading to heart failure.

What causes aortic stenosis, and how is it identified?

Aortic stenosis is often due to age-related calcium buildup and scarring on the valve: in America, more than 20% of people 65 and older have aortic stenosis. Other causes include rheumatic heart disease from an untreated infection, or an abnormal valve structure such as a bicuspid aortic valve.

Aortic stenosis is frequently diagnosed and monitored by an ultrasound of the heart (echocardiogram). Based on measurements taken during this imaging test, aortic stenosis is considered mild, moderate, or severe.

Severe aortic stenosis can lead to varied symptoms, such as shortness of breath, swollen ankles, and chest pain. Once symptoms occur, aortic stenosis can be life-threatening if not treated.

How is aortic stenosis treated?

If you’ve been diagnosed with aortic stenosis, you and your health provider should develop a plan to monitor changes in severity and symptoms. For example, an echocardiogram is recommended every one to two years for people with moderate stenosis.

If you have severe aortic stenosis, it’s best to also have a cardiologist or valve specialist monitor you.

Current guidelines from the American College of Cardiology and the American Heart Association recommend replacing the valve when symptoms develop and severe aortic stenosis is diagnosed. In some cases, a valve with moderate stenosis is replaced if a person is undergoing an open-heart surgery for another reason, such as cardiac bypass surgery for coronary artery disease.

Two main types of aortic valve replacement may be offered:

  • Surgical aortic valve replacement. During open-heart surgery, your aortic valve is replaced with a mechanical (usually metal) or bioprosthetic (made from other tissues) valve.
  • Transcatheter aortic valve replacement (TAVR or TAVI). This is a minimally invasive surgical procedure, similar to a heart catheterization used to take images of heart blood vessels (coronary artery angiography). Your existing valve is replaced with a bioprosthetic valve through a tube called a catheter that is inserted into a blood vessel in the leg and guided to the heart.

Some people who are not able to have open-heart surgery for medical reasons can improve their chance of survival if transcatheter aortic valve replacement is an appropriate option. Participants in the landmark PARTNER trial had aortic stenosis severe enough to cause symptoms, but were not good candidates for open-heart surgery. Only 30% of those who were able to have TAVI died within a year of symptom onset, compared with 50% of those who could not have this procedure.

Health disparities in treating aortic stenosis

While treatment of aortic stenosis continues to advance, several groups lag behind in key measures that affect outcomes. Many health care providers may monitor aortic stenosis and start treatment plans, often working as a team with heart experts like cardiologists and cardiothoracic surgeons. Yet African American patients with aortic valve disease are only half as likely to be referred to a cardiologist as white patients, according to research published in the American Journal of Cardiology. TAVR and open-heart aortic valve replacement are similarly successful for both populations, but one study found African Americans are less likely than whites to receive these treatments and refuse them more often.

Additionally, income status and where people live in relationship to available heart valve specialists may disproportionately affect care. For example:

Why do findings like these matter? Because unequal access to care — including travel, insurance, payment, and location near a center for aortic valve replacement — affect the ability to pursue good treatment.

How to help ensure that you’ll get good treatment

First, seek medical advice if you experience chest pain, shortness of breath, dizziness, lightheadedness, or fainting. Depending on the likelihood that the cause is aortic stenosis, a doctor may recommend having an ultrasound of your heart.

If you are diagnosed with moderate or severe aortic stenosis, ask to follow up with a cardiologist. The cardiologist can monitor your heart health and develop a treatment plan, as needed.

If aortic valve replacement is recommended, ask questions about

  • the risks and benefits of an open-heart approach versus TAVR
  • which type of valve (metallic or bioprosthetic) is recommended, and why
  • your overall risks based on health and age
  • your expected recovery.

Lastly, given inequalities within medicine, it is important to advocate for your care, despite challenges you may face.

Follow us on Twitter @DanAmponsahMD and @HannaGaggin

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