Sex differences in aortic stenosis: from pathophysiology to treatment

ABSTRACT

Introduction: In aortic stenosis (AS), there are clear sex differences in clinical presentation, left ventricular (LV) response to pressure overload, and pathophysiology of valvular calcification. These differences may affect outcome following valve intervention.

Area covered: This review aims to discuss sex differences in clinical presentation, pathophysiology of aortic valve calcification, LV remodeling in view of historic and recent echocardiographic and cardiac magnetic resonance imaging studies, and outcome after valve intervention. In addition, it will also provide some brief insights on the exercise physiology in women and men with AS.

Expert commentary: Women at presentation are often older, have higher prevalence of hypertension and diastolic dysfunction, while men are younger, and more often have a bicuspid aortic valve and higher atherosclerotic disease burden. Men have more valve calcification than women for a given severity of AS and develop different patterns of LV remodeling and myocardial fibrosis. Although women tend to walk shorter on treadmill and achieve lower metabolic equivalents, they achieve similar peak heart rates and blood pressure, and the frequency of revealed symptoms during exercise test is comparable in both sexes. Men are more likely to undergo a surgical AVR with better outcome, while women have generally better outcome after TAVI.

KEYWORDS:

• Aortic stenosis
• sex differences
• LV remodeling
• outcome
• TAVI
• aortic valve replacement

Article highlights

• Women with AS are older at presentation, have more severe valvular dysfunction and more advanced symptoms, and a higher prevalence of hypertension than men.

• Men are younger, have higher prevalence of BAV, atherosclerotic vascular disease and chronic kidney disease.

• LV in women and men remodel differently in response to AS-induced pressure overload.

• Men demonstrate more advanced maladaptive LV remodeling in response to pressure overload than women.

• Women reach the similar degree of AS severity as men with lesser amount aortic valve calcification loads.

• Women more often undergo TAVI while men undergo AVR, dependent on concomitant comorbidities and their fitness for the type of intervention.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer Disclosures

Peer reviewers on this manuscript have no relevant financial relationships or otherwise to disclose.

Additional information

Funding

This paper was not funded.