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The medically managed patient with severe symptomatic aortic stenosis in the TAVR era: Patient characteristics, reasons for medical management, and quality of shared decision making at heart valve treatment centers.

Publication ,  Journal Article
Dharmarajan, K; Foster, J; Coylewright, M; Green, P; Vavalle, JP; Faheem, O; Huang, P-H; Krishnaswamy, A; Thourani, VH; McCoy, LA; Wang, TY
Published in: PLoS One
2017

BACKGROUND: Little is known about patients with severe symptomatic aortic stenosis (AS) who receive medical management despite evaluation at a heart valve treatment center. OBJECTIVE: We identified patient characteristics associated with medical management, physician-reported reasons for selecting medical management, and patients' perceptions of their involvement and satisfaction with treatment selection. METHODS AND RESULTS: Of 454 patients evaluated for AS at 9 established heart valve treatment centers from December 12, 2013 to August 19, 2014, we included 407 with severe symptomatic AS. Information was collected using medical record review and survey of patients and treating physicians. Of 407 patients, 212 received transcatheter aortic valve replacement (TAVR), 124 received surgical aortic valve replacement (SAVR), and 71 received medical management (no SAVR/TAVR). Thirty-day predicted mortality was higher in patients receiving TAVR (8.7%) or medical management (9.8%) compared with SAVR (3.4%) (P<0.001). Physician-reported reasons for medical management included patient preference (31.0%), medical futility (19.7%), inoperability/anatomic infeasibility (11.3%), and inadequate vascular access (8.5%). Compared with patients receiving AVR, medically managed patients were less likely to report that they received enough information about the pros and cons of treatment options (P = 0.03), that their physicians involved them in treatment decisions (P<0.001), and that final decisions were the right ones (P<0.001). CONCLUSIONS: Patient preference was the most common physician-reported reason for selecting non-invasive AS management, yet patients not undergoing AVR after valve center evaluation reported being less likely to receive sufficient education about treatment options and more likely to feel uncertain about final treatment decisions. Greater attention to shared decision making may improve the experience of care for this vulnerable group of patients.

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Published In

PLoS One

DOI

EISSN

1932-6203

Publication Date

2017

Volume

12

Issue

4

Start / End Page

e0175926

Location

United States

Related Subject Headings

  • Severity of Illness Index
  • Patient Participation
  • Male
  • Humans
  • Heart Valve Prosthesis Implantation
  • General Science & Technology
  • Female
  • Decision Making
  • Cohort Studies
  • Aortic Valve Stenosis
 

Citation

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Dharmarajan, K., Foster, J., Coylewright, M., Green, P., Vavalle, J. P., Faheem, O., … Wang, T. Y. (2017). The medically managed patient with severe symptomatic aortic stenosis in the TAVR era: Patient characteristics, reasons for medical management, and quality of shared decision making at heart valve treatment centers. PLoS One, 12(4), e0175926. https://doi.org/10.1371/journal.pone.0175926
Dharmarajan, Kumar, Jill Foster, Megan Coylewright, Philip Green, John P. Vavalle, Osman Faheem, Pei-Hsiu Huang, et al. “The medically managed patient with severe symptomatic aortic stenosis in the TAVR era: Patient characteristics, reasons for medical management, and quality of shared decision making at heart valve treatment centers.PLoS One 12, no. 4 (2017): e0175926. https://doi.org/10.1371/journal.pone.0175926.
Dharmarajan K, Foster J, Coylewright M, Green P, Vavalle JP, Faheem O, Huang P-H, Krishnaswamy A, Thourani VH, McCoy LA, Wang TY. The medically managed patient with severe symptomatic aortic stenosis in the TAVR era: Patient characteristics, reasons for medical management, and quality of shared decision making at heart valve treatment centers. PLoS One. 2017;12(4):e0175926.

Published In

PLoS One

DOI

EISSN

1932-6203

Publication Date

2017

Volume

12

Issue

4

Start / End Page

e0175926

Location

United States

Related Subject Headings

  • Severity of Illness Index
  • Patient Participation
  • Male
  • Humans
  • Heart Valve Prosthesis Implantation
  • General Science & Technology
  • Female
  • Decision Making
  • Cohort Studies
  • Aortic Valve Stenosis