Risk Stratification of Patients With Moderate Aortic Stenosis Using Aortic Valve Calcium

Objectives To evaluate whether aortic valve calcium (AVC) scoring by cardiac CT can enhance risk stratification and identify high-risk patients among those with moderate aortic stenosis (AS).

Moderate AS is traditionally considered benign, yet emerging evidence suggests a subset may experience adverse outcomes similar to those with severe AS. AVC scoring has been validated for diagnosing severe AS but its prognostic value in moderate AS remains unclear.

A retrospective cohort study of 606 patients with moderate aortic stenosis (MAS) for whom aortic valve calcium (AVC) assessment was recommended on echocardiogram reports. Patients were categorized into two groups: those who underwent AVC (n=159) and those who did not (n=447). Primary outcomes included aortic valve replacement (AVR) and all-cause mortality. Secondary outcomes included time to severe AS diagnosis and time to AVR.

A significantly higher proportion of patients in the CT cohort reached a diagnosis of severe AS (28.8% vs. 19.9%, p=0.037) and underwent valve intervention (32.6% vs. 14.1%, p<0.001) compared to the no-CT cohort. Patients underwent valve intervention mostly at the severe AS stage. All-cause mortality was markedly lower in the CT cohort (7.6% vs. 24.9%, p<0.001); difference being driven by excess non-cardiovascular mortality in the no-CT cohort (61.0% vs. 7.9%, p2000 AU and females >1200 AU) were more likely to undergo valve intervention compared with non-severe AVC (HR 2.60, 95% CI 1.42-4.74, p=0.002). Patients in the CT cohort were more likely to undergo valve intervention (HR 3.17, CI 2.04-4.91, p<0.001), and had a significantly lower all-cause mortality (HR 0.32, CI 0.16-0.61, p=0.001) compared to the no-CT cohort.

A practice algorithm incorporating AVC for risk stratification of MAS patients can lead to better outcomes. Role of AVC based decision-making in patients with MAS needs further study in a randomized trial. Competing Interest Statement Dr. Philippe Pibarot has received funding from Edwards Lifesciences, Medtronic, Pi-Cardia, and Cardiac Phoenix for echocardiography core laboratory analyses and research studies in the field of transcatheter valve therapies, for which he received no personal compensation. He has received lecture fees from Edwards Lifesciences and Medtronic. Dr. Jonathon Leipsic has held institutional research core lab agreements with Medtronic, Edwards Lifesciences, Abbott, Boston Scientific, and Pi-Cardia. Rest of the authors have no conflict of interest to disclose. Clinical Trial Not applicable. This study is a retrospective observational analysis and does not meet the definition of a clinical trial requiring registration. Funding Statement The authors received no external funding or third-party support for any aspect of the submitted work. Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The study was reviewed and determined to be exempt by the Institutional Review Board of West Virginia University IRB. No protocol number was assigned. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Data Availability Data will be made available upon request