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Therapeutic Decision-Making and Outcomes in Elderly Patients With Severe Symptomatic Aortic Stenosis: Prognostic Implications of Elderly Patients' Initial Decisions

Background: Despite clear indications for intervention, therapeutic decision-making for elderly patients with severe symptomatic aortic stenosis (AS) remains a complex issue due to the wide variation in individual risk profiles and the involvement of patients' subjective preferences. We aimed t...

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Autores principales: Zhao, Qinghao, Xu, Haiyan, Liu, Qingrong, Ye, Yunqing, Zhang, Bin, Li, Zhe, Gao, Runlin, Wu, Yongjian
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Frontiers Media S.A. 2021
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8350052/
https://www.ncbi.nlm.nih.gov/pubmed/34381825
http://dx.doi.org/10.3389/fcvm.2021.696763
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author Zhao, Qinghao
Xu, Haiyan
Liu, Qingrong
Ye, Yunqing
Zhang, Bin
Li, Zhe
Gao, Runlin
Wu, Yongjian
author_facet Zhao, Qinghao
Xu, Haiyan
Liu, Qingrong
Ye, Yunqing
Zhang, Bin
Li, Zhe
Gao, Runlin
Wu, Yongjian
author_sort Zhao, Qinghao
collection PubMed
description Background: Despite clear indications for intervention, therapeutic decision-making for elderly patients with severe symptomatic aortic stenosis (AS) remains a complex issue due to the wide variation in individual risk profiles and the involvement of patients' subjective preferences. We aimed to investigate the reasons leading to the decisions against intervention and the consequences thereof on survival. Methods: Data were derived from the China Elderly Valve Disease (China-DVD) Cohort Study on patients aged ≥60-year-old with severe symptomatic AS consecutively enrolled between September to December 2016. Patients were analyzed according to the initial therapeutic decisions made by consensus between patients and physicians at the time of the index evaluation: intervention group (patients who were evaluated as suitable for intervention and accepted the treatment proposal); patient-refusal group (patients who were evaluated as suitable for intervention but refused due to subjective preferences); physician-deny group (patients who were denied intervention by physicians after evaluation). The least absolute shrinkage and selection operator (LASSO)-penalized logistic regression model was used to identify the factors associated with physicians' decisions against intervention. Twelve-month survival was analyzed using Cox proportional hazards models, with multivariate adjustment using inverse probability weighting (IPW). Results: Among the enrolled 456 elderly patients with severe symptomatic AS, 52 (11.4%) patients refused intervention and 49 (10.7%) patients were denied intervention by their physicians. LASSO-penalized logistic regression model identified that reduced left ventricular ejection fraction and increased EuroSCORE-II were strongly associated with physicians' decisions against intervention. At 12-month follow-up, only 8 (15.4%) patients who initially refused the intervention proposal underwent the subsequent intervention, with an average delay of 195 days. Patients' initial decisions against intervention were significantly associated with 12-month mortality, even after IPW adjustment (Hazard ratio: 2.61; 95% confidence interval: 1.09–6.20; P = 0.031). Conclusions: The decision against intervention was taken in about one-fifth of elderly patients with symptomatic severe AS, half of which were due to patients' subjective preferences. Surgical risk remains the primary concern for physicians when making therapeutic decisions. Elderly patients' initial decisions against intervention have a profound impact on subsequent intervention rates and prognosis, and therefore should be treated as a “risk factor” at the subjective level. Clinical Trial Registration: clinicaltrials.gov/ct2/show/NCT02865798, China elDerly Valve Disease (China-DVD) cohort study (NCT02865798).
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spelling pubmed-83500522021-08-10 Therapeutic Decision-Making and Outcomes in Elderly Patients With Severe Symptomatic Aortic Stenosis: Prognostic Implications of Elderly Patients' Initial Decisions Zhao, Qinghao Xu, Haiyan Liu, Qingrong Ye, Yunqing Zhang, Bin Li, Zhe Gao, Runlin Wu, Yongjian Front Cardiovasc Med Cardiovascular Medicine Background: Despite clear indications for intervention, therapeutic decision-making for elderly patients with severe symptomatic aortic stenosis (AS) remains a complex issue due to the wide variation in individual risk profiles and the involvement of patients' subjective preferences. We aimed to investigate the reasons leading to the decisions against intervention and the consequences thereof on survival. Methods: Data were derived from the China Elderly Valve Disease (China-DVD) Cohort Study on patients aged ≥60-year-old with severe symptomatic AS consecutively enrolled between September to December 2016. Patients were analyzed according to the initial therapeutic decisions made by consensus between patients and physicians at the time of the index evaluation: intervention group (patients who were evaluated as suitable for intervention and accepted the treatment proposal); patient-refusal group (patients who were evaluated as suitable for intervention but refused due to subjective preferences); physician-deny group (patients who were denied intervention by physicians after evaluation). The least absolute shrinkage and selection operator (LASSO)-penalized logistic regression model was used to identify the factors associated with physicians' decisions against intervention. Twelve-month survival was analyzed using Cox proportional hazards models, with multivariate adjustment using inverse probability weighting (IPW). Results: Among the enrolled 456 elderly patients with severe symptomatic AS, 52 (11.4%) patients refused intervention and 49 (10.7%) patients were denied intervention by their physicians. LASSO-penalized logistic regression model identified that reduced left ventricular ejection fraction and increased EuroSCORE-II were strongly associated with physicians' decisions against intervention. At 12-month follow-up, only 8 (15.4%) patients who initially refused the intervention proposal underwent the subsequent intervention, with an average delay of 195 days. Patients' initial decisions against intervention were significantly associated with 12-month mortality, even after IPW adjustment (Hazard ratio: 2.61; 95% confidence interval: 1.09–6.20; P = 0.031). Conclusions: The decision against intervention was taken in about one-fifth of elderly patients with symptomatic severe AS, half of which were due to patients' subjective preferences. Surgical risk remains the primary concern for physicians when making therapeutic decisions. Elderly patients' initial decisions against intervention have a profound impact on subsequent intervention rates and prognosis, and therefore should be treated as a “risk factor” at the subjective level. Clinical Trial Registration: clinicaltrials.gov/ct2/show/NCT02865798, China elDerly Valve Disease (China-DVD) cohort study (NCT02865798). Frontiers Media S.A. 2021-07-26 /pmc/articles/PMC8350052/ /pubmed/34381825 http://dx.doi.org/10.3389/fcvm.2021.696763 Text en Copyright © 2021 Zhao, Xu, Liu, Ye, Zhang, Li, Gao and Wu. https://creativecommons.org/licenses/by/4.0/This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
spellingShingle Cardiovascular Medicine
Zhao, Qinghao
Xu, Haiyan
Liu, Qingrong
Ye, Yunqing
Zhang, Bin
Li, Zhe
Gao, Runlin
Wu, Yongjian
Therapeutic Decision-Making and Outcomes in Elderly Patients With Severe Symptomatic Aortic Stenosis: Prognostic Implications of Elderly Patients' Initial Decisions
title Therapeutic Decision-Making and Outcomes in Elderly Patients With Severe Symptomatic Aortic Stenosis: Prognostic Implications of Elderly Patients' Initial Decisions
title_full Therapeutic Decision-Making and Outcomes in Elderly Patients With Severe Symptomatic Aortic Stenosis: Prognostic Implications of Elderly Patients' Initial Decisions
title_fullStr Therapeutic Decision-Making and Outcomes in Elderly Patients With Severe Symptomatic Aortic Stenosis: Prognostic Implications of Elderly Patients' Initial Decisions
title_full_unstemmed Therapeutic Decision-Making and Outcomes in Elderly Patients With Severe Symptomatic Aortic Stenosis: Prognostic Implications of Elderly Patients' Initial Decisions
title_short Therapeutic Decision-Making and Outcomes in Elderly Patients With Severe Symptomatic Aortic Stenosis: Prognostic Implications of Elderly Patients' Initial Decisions
title_sort therapeutic decision-making and outcomes in elderly patients with severe symptomatic aortic stenosis: prognostic implications of elderly patients' initial decisions
topic Cardiovascular Medicine
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8350052/
https://www.ncbi.nlm.nih.gov/pubmed/34381825
http://dx.doi.org/10.3389/fcvm.2021.696763
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