Increased mortality in women with severe aortic stenosis and low ejection fraction
Bibliographic record
Abstract
Abstract Background Women with severe aortic stenosis (AS) tend to be operated with more advanced valvular heart disease. They also have worse survival after aortic valve replacement (AVR). This difference between sexes in surgical referral and its relationship to mortality have not been previously studied in patients with severe AS and low left ventricular ejection fraction (LVEF). Purpose To assess sex differences in patients with severe AS and low LVEF, and to evaluate their potential association with mortality. Methods This is a retrospective study of consecutive patients presenting with a diagnosis of severe AS and low LVEF (≤50%) on echocardiogram, at the Quebec Heart and Lung Institute between 2004–2015. Patients were excluded if they had congenial or rheumatic heart disease, and/or more than moderate aortic regurgitation. Patients were compared according to sex for incidence of AVR and long-term all-cause mortality with univariate (Kaplan-Meyer with log-rank test), and multivariate analysis (Cox regression model) adjusting for baseline comorbidities, LVEF and severity of valvular disease. Results Our database had a total of 1129 patients, of which 578 were included in the analysis. There were 149 women (26%). Mean follow-up time was 3.10±3.04 years (1795 patient-years). There were 279 AVR and 284 deaths. Women were older (77±11 vs 74±10 years, p=0.004), and had less coronary artery disease (60% vs 79%, p<0.001) and dyslipidemia (55% vs 72%, p<0.001). Women had comparable severity of AS at baseline, with better LVEF (37% vs 35%, p=0.02). In univariate analysis, there was a strong tendency for increased mortality in women compared to men (p=0.06). After comprehensive baseline adjustement, female sex was predictive of mortality (HR 1.33 [1.00–1.75], p=0.04). Women were also less likely to be operated than men (HR 0.70 [0.51–0.94], p=0.02). After further adjustment for AVR as a time-dependent variable, there was only a trend toward the significance of sex as a predictor of mortality (p=0.12). In a sex-specific analysis of predictors of mortality, LVEF was predictive of mortality in women (HR 0.97 [0.94–0.99], p=0.007), while not in men (0.99 [0.98–1.01], p=0.51). Conclusions Despite adjustment for comorbidities and AS severity, women were less likely to be referred to AVR and had a higher overall mortality. After adjustment for AVR, female sex was no longer a predictor of mortality, underlying the negative impact of the lack of treatment in women with decreased LVEF. Thus underrecognition and suboptimal management of severe AS in female patients with low LVEF should be further investigated to identify contributing factors and possible solutions. Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): Dr Clavel has received a grant from the Heart and Stroke Foundation of Canada
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.000 | 0.001 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.000 | 0.000 |
| Bibliometrics | 0.001 | 0.001 |
| Science and technology studies | 0.000 | 0.000 |
| Scholarly communication | 0.000 | 0.000 |
| Open science | 0.000 | 0.000 |
| Research integrity | 0.000 | 0.000 |
| Insufficient payload (model declined to judge) | 0.003 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".