How should we manage symptomatic aortic stenosis in the patient who is 80 or older?

摘要

Cardiologists can expect to see an increasing number of elderly and very elderly patients with symptomatic aortic stenosis. By the year 2000, 2 million people in England (4.2% of the population) will be aged 80 years or older. Aortic stenosis is common in this age group: the best estimate of its prevalence is provided by a population-based study in Finland which found severe stenosis (valve area < 0.8 cm~2 by Doppler echocardiography) in 2.9% (95% confidence interval 1.4 to 5.1%) of randomly selected people aged 75-86, half of whom had symptoms and were regarded as candidates for valve replacement. Applied to England, and assuming survival from the onset of symptoms to be 4 years, these figures predict a potential need for > 3500 aortic valve replacements per year in patients over 80. In a cash-limited system of health care, the provision of cardiac surgery for elderly patients will reduce the funds available for the treatment of younger patients. Several methods, all with limitations, have been proposed to deal with such competing claims. But any judgement on resource allocation must take into account the health gains conferred by the intervention. While there is no dispute about its value in younger patients with symptomatic aortic stenosis, is there good evidence that patients over 80 can benefit from valve replacement?