A Decision-Making Framework for Objective Risk Assessment in Older Adults with Severe Symptomatic Aortic Stenosis
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The increasing prevalence of severe symptomatic aortic stenosis (AS) in older adults is now considered a major public health concern. Since medical therapy has not been shown to improve prognosis, surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR) are the best options currently available, yet not all patients benefit. Objective assessment of risk versus benefit for SAVR and TAVR is essential. Clinical prediction models (CPM) have been created to augment subjective physician estimates of risk and have been shown to improve the accuracy of risk predictions. This manuscript presents the rationale for a framework of objective evaluation of risk assessment and decision making by linking clinically relevant CPM (life expectancy, Society of Thoracic Surgery, and TAVR risk calculators) with two additional concepts of lag time to benefit and competing risks that are relatively novel to the clinical arena. We believe that such aggregate framework can improve the assessment of risk and benefit and thereby facilitate a more informed and standardized shared decision-making process in the care of older adults with severe symptomatic AS.
KeywordsAge Older adult Risk stratification Clinical prediction models Life expectancy Standard aortic valve replacement Transcatheter aortic valve replacement Lag time to benefit Competing risks Shared decision making
Dr. Forman is supported in part by the NIA grant P30 AG024827 and VA Office of Rehabilitation Research and Development grant F0834-R. Other authors were not funded for this project.
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Conflict of Interest
Ashok Krishnaswami, Daniel E. Forman, Mathew S. Maurer, and Sei J. Lee declare that they have no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
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