TAVR for moderate aortic stenosis cut heart-failure events, not deaths

Design

International, open-label randomised trial (PROGRESS)

Population

744 patients, mean age 78, with moderate aortic stenosis and an at-risk feature

Primary outcome

Death from any cause or a heart-failure event at 2 years

Effect

16.7% vs 23.9%; risk difference −7.2 points (95% CI −13.1 to −1.3)

PROGRESS randomised 744 patients, mean age 78, with moderate aortic stenosis and at least one feature linked to faster progression, such as symptoms or ventricular changes. Half had transfemoral TAVR; half were followed with surveillance, which is what guidelines currently advise.

At two years, death or a heart-failure event occurred in 16.7% after TAVR and 23.9% under surveillance, a 7.2-point difference (95% CI 13.1 to 1.3 points). The gap came almost entirely from heart-failure events (10.8% against 19.0%). Deaths were similar: 8.4% with TAVR, 7.3% with surveillance.

For a clinician outside cardiology, the practical point is that "moderate" aortic stenosis in an older patient with breathlessness or a struggling ventricle is not automatically a watch-and-wait finding. The trial was open-label and funded by the valve maker, and guidelines have not changed, so this argues for referral and discussion rather than for the procedure.

• Refer older patients with moderate aortic stenosis and breathlessness for cardiology review rather than waiting for the next scheduled echo.
• Ask about exertional symptoms in anyone whose echo reports moderate aortic stenosis.
• Explain that the benefit seen was fewer heart-failure events, not longer life.
• Guidelines still advise surveillance for moderate stenosis.

Why it matters

It questions the habit of filing moderate aortic stenosis as harmless until it turns severe.

Don't overread it

No survival benefit, open-label and industry funded; the guideline has not changed.

The statistics, in plain English

A 7.2-point absolute difference means roughly one death or heart-failure event avoided for every 14 patients over two years. The confidence interval is wide, and its smaller end is a gain of about one point. Because death rates were similar, the result rests on heart-failure events, which are more open to judgement in a trial where everyone knew who had the valve.

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