
==== Front
Perm J
tpj
tpj
The Permanente Journal
1552-5767
1552-5775
The Permanente Press

39049576
10.7812/TPP/24.038
TPJ-24-038
Original Research
Racial and Ethnic Differences in the Prevalence of Severe Aortic Stenosis by Echocardiography
Allahwerdy Salam BS 1
Xie Fagen PhD 2
Zhou Botao MS 2
Wu Yi-Lin MS 2
Wessler Benjamin MD 3
Chen Wansu PhD 2
http://orcid.org/0000-0001-6121-6452
Lee Ming-Sum MD, PhD 4
1 Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
2 Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
3 Department of Cardiology, Tufts University Medical Center, Boston, CA, USA
4 Department of Cardiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, USA
Ming-Sum Lee, MD, PhD Mingsum.Lee@kp.org
2024
25 7 2024
28 3 98106
© 2024 The Authors.
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ Published by The Permanente Federation LLC under the terms of the CC BY-NC-ND 4.0 license https://creativecommons.org/licenses/by-nc-nd/4.0/.

Abstract

Background

Understanding the burden of aortic stenosis (AS) across diverse racial and ethnic populations is important to ensure equitable resource allocation. This study explored whether severe AS rate varies by race and ethnicity.

Methods

The rates of severe AS, stratified by race and ethnicity, were calculated among 615,038 adults with a transthoracic echocardiogram. Logistic regression analysis was performed to identify factors associated with severe AS.

Results

Severe AS rates ranged from 0.08% in adults < 50 years old to 3.8% in those ≥ 90 years old. Compared to non-Hispanic White and Asian American [adjusted odds ratio (aOR) = 0.47, 95% confidence interval (CI): 0.42–0.53] and non-Hispanic Black (aOR = 0.44, 95% CI: 0.39–0.50) patients were less likely to have severe AS, whereas Hispanic patients (aOR = 0.91, 95% CI: 0.87–0.98) had near similar likelihood. Age was the strongest risk factor for severe AS (compared to age < 50 years, aOR = 21.8, 95% CI: 17.8–26.6 for age 80–89 years, and aOR = 43.8, 95% 35.5–54.0 for age ≥ 90 years). Additional factors associated with severe AS included male sex (aOR = 1.38, 95% CI: 1.30–1.46) and diabetes (aOR = 1.23, 95% CI: 1.15–1.31).

Conclusions

Asian American and non-Hispanic Black adults had lower rates of severe AS compared to White and Hispanic patients. The rate of severe AS progressively increases with age in all racial and ethnic groups, with higher rates in men compared with women. With a demographic shift toward an aging and more diverse population, the burden of AS is anticipated to rise. Ensuring adequate allocation of resources to meet the evolving needs of a diverse population remains a shared health care imperative.

Keywords:

Aortic stenosis
echocardiogram
prevalence
==== Body
pmcIntroduction

Aortic stenosis (AS) is the leading type of valvular heart disease requiring intervention in high-income countries.1,2 If left untreated, patients with symptomatic AS face a mortality rate as high as 50% at 1 year.3 The incidence of AS rises with aging.4 With the number of individuals ≥ 65 years old projected to nearly double by 2060, the impact of AS on health care resource utilization is expected to significantly increase.2

Treatment for AS involves either surgical aortic valve replacement or transcatheter aortic valve replacement (TAVR).5 Patients from minority groups and those who are socioeconomically disadvantaged have reduced access to these procedures.6 A recent study showed that increasing TAVR procedure rates correlated with lower mortality in the non-Hispanic White population but not in the non-Hispanic Black or Hispanic populations.7 As the older population becomes more racially and ethnically diverse,8 understanding the prevalence of AS in adults from diverse racial and ethnic backgrounds is critical for resource planning and for understanding and addressing potential care disparities.

The differences in AS prevalence across racial and ethnic groups have remained understudied. Studies reporting AS prevalence have focused primarily on non-Hispanic White patients.9,10 Some studies included non-Hispanic Black patients, and a very few studies reported information in Hispanic and Asian American patients.11–13 These studies have been limited by the relatively small cohort size, biased ascertainment of AS by reliance on hospitalization data or claims data, and referral bias from data obtained from academic tertiary-care centers. The goal of the present study was to examine the rate of severe AS in a large racially and ethnically diverse population referred for echocardiogram.

Methods

The institutional review board at Kaiser Permanente Southern California approved this study. Informed consent was waived for this study due to minimal patient risk and that there was no direct patient contact.

This was a cross-sectional study that included adult members from Kaiser Permanente Southern California. This study followed the guideline as outlined in the Strengthening the Reporting of Observational Studies in Epidemiology document.14

Data source

Kaiser Permanente Southern California is an integrated health care system in southern California. It provides health care coverage to > 4.8 million members. The membership is racially and ethnically diverse.15 Comprehensive medical information, including administrative and health care utilization data, is prospectively captured and stored in a centralized data warehouse.16

Identification of patients with AS

Consecutive adults ≥ 18 years old who had a transthoracic echocardiogram (TTE) between January 1, 2011, and December 31, 2021, were included. TTEs were performed as part of the usual clinical care and included studies completed in outpatient, inpatient, and emergency department settings. For individuals with multiple echocardiograms, their first echocardiogram during the study period was included. The study excluded patients who were not active health plan members at the time of TTE performance or had unknown age or sex.

Echocardiogram reports were obtained from electronic health records. The severity of AS was identified based on the final impression submitted by the resulting cardiologist. AS severity was categorized into four groups: 1) no AS, which included no AS and aortic sclerosis; 2) mild AS, which included mild AS and mild-to-moderate AS; 3) moderate AS, which included moderate AS and moderate-to-severe AS; and 4) severe AS, which included severe AS and very severe AS.

Covariates

Demographic data was ascertained from the Kaiser Permanente Southern California Research Data Warehouse.16 Race and ethnicity information was self-reported and categorized as Asian American, non-Hispanic Black (Black), Hispanic (Hispanic), non-Hispanic White (White), and other (multiple races and ethnicity, unknown, declined, or missing).15 Medical comorbidities were identified from electronic health records.

Statistical analysis

Continuous variables were summarized as medians with 25th and 75th percentiles, whereas categorical variables were summarized as counts and percentages. The rate of severe AS was calculated and stratified by age, sex, and race and ethnicity. The denominator for the rate calculations was the number of health plan members who underwent TTE during the study period. Estimates of the rate of AS were presented as proportions with 95% confidence intervals (CIs). Age- and sex-standardized rate estimates were calculated. The 2020 US Census population was used as the reference population. Logistic regression models were constructed to evaluate the association between clinical factors and the presence of severe AS. Odds ratios (ORs) were reported with corresponding 95% CIs. Multivariable logistic regression included the following variables: age, sex, race and ethnicity, hypertension, diabetes, chronic kidney disease, obesity, and diabetes. All p values were 2-sided. p < 0.05 was considered statistically significant. Statistical analyses were conducted using Stata 17/MP 17.0 (StataCorp LLC, College Station, TX) or SAS version 9.4 (SAS Institute Inc).

Results

Study cohort

Among 677,106 adults with a TTE, 62,068 met ≥ 1 exclusion criteria: 16 were nonmembers, 61,319 did not have race and ethnicity information, 733 had reports that did not comment on the aortic valve. The final cohort included 615,038 individuals. Table 1 shows the baseline characteristics. The median (interquartile range) age was 65 (52–75) years, and 320,276 (52.1%) were women, 314,801 (51.2%) were non-Hispanic White, 79,125 (12.9%) were non-Hispanic Black, 141,364 (23.0%) were Hispanic, and 66,296 (10.8%) were Asian American.

Table 1: Baseline characteristics

Characteristic	Non-Hispanic White (N = 314,801)	Non-Hispanic Black
(N = 79,125)	Hispanic (N = 141,364)	Asian American (N = 66,296)	Other
(N = 13,452)	
Age, y	
Group age, median (IQR)	67 (57, 77)	63 (51, 74)	60 (44, 72)	64 (51, 74)	59 (44, 69)	
≥ 80, n (%)	63,445 (20.2)	11,451 (14.5)	17,768 (12.6)	9017 (13.6)	1147 (8.5)	
Sex, n (%)	
Male	159,035 (50.5)	33,437 (42.3)	63,546 (45.0)	31,969 (48.2)	6775 (50.4)	
Female	155,766 (49.5)	45,688 (57.7)	77,818 (55.1)	34,327 (51.8)	6677 (49.6)	
Aortic stenosis, n (%)	
None	286,419 (91.0)	75,758 (95.7)	132634 (93.8)	62,933 (94.9)	12,779 (95.0)	
Mild	15,316 (4.9)	2046 (2.6)	4905 (3.5)	2110 (3.2)	409 (3.0)	
Moderate	6194 (2.0)	701 (0.9)	1802 (1.3)	589 (0.9)	125 (0.9)	
Severe	3274 (1.0)	307 (0.4)	990 (0.7)	278 (0.4)	61 (0.5)	
Prosthetic valve, n (%)	3598 (1.1)	313 (0.4)	1033 (0.7)	386 (0.6)	78 (0.6)	
Comorbidities, n (%)	
Hypertension	185,105 (58.8)	54,801 (69.3)	76,357 (54.0)	38,912 (58.7)	6866 (51.0)	
Diabetes	70,403 (22.4)	25,651 (32.4)	45,876 (32.5)	21,238 (32.0)	3790 (28.2)	
Obesity	78,148 (24.8)	26,374 (33.3)	43,687 (30.9)	7559 (11.4)	3027 (22.5)	
Heart failure	37,190 (11.8)	11,397 (14.4)	14,079 (10.0)	5757 (8.7)	1280 (9.5)	
CKD	62,629 (19.9)	19,724 (24.9)	25,093 (17.8)	12,127 (18.3)	2079 (15.5)	
COPD/asthma	71,807 (22.8)	18,720 (23.7)	25,961 (18.4)	10,358 (15.6)	2305 (17.2)	
CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease; IQR , interquartile range.

Rate of ASAortic Stenosis

Among the final cohort of 615,038 individuals, 39,107 (6.3%) patients had AS, with 24,786 (4.0%) mild AS, 9411 (1.5%) moderate AS, and 4901 (0.8%) severe AS. Figure 1 shows the rate of severe AS stratified by sex and age. The rate of severe AS progressively increased with age. The rates of severe AS ranged from 0.08% among adults < 50 years old to 3.8% among adults ≥ 90 years old. Severe AS rates were greater in men compared to women in every age group (Figure 2). In women, the rates increased from 0.06% among individuals < 50 years old to 3.7% in individuals ≥ 90 years old. In men, the rates of severe AS ranged from 0.11% among individuals < 50 years old to 3.9% in individuals ≥ 90 years old.

Figure 1: Rate of severe AS stratified by age and sex. AS = aortic stenosis.

Figure 2: Sex- and age-specific rate of severe AS stratified by race and ethnicity: (A) non-Hispanic White, (B) non-Hispanic Black, (C) Hispanic, and (D) Asian. AS = aortic stenosis.

Racial and ethnic differences in severe AS rates

Age-specific and age-adjusted rates of severe AS are shown in Table 2. Age- and sex-standardized severe AS rates were highest in non-Hispanic White men (0.58%) and non-Hispanic White women (0.46%). Compared to non-Hispanic White patients, severe AS rates were lower in non-Hispanic Black men (0.19%) and non-Hispanic Black women (0.14%). Rates of severe AS were also low in Asian American men (0.21%) and Asian American women (0.17%).

Table 2: Age-specific and age-adjusted rates of severe AS by sex and race and ethnicity

Race and ethnicity and age, y	Severe AS (N)	Base population (N)	Age-specific rate (%)	Age-standardized rate (%)a	Severe AS (N)	Base population (N)	Age-specific rate (%)a	Age-standardized rate (%)	
All patients	
18–49	44	76,045	0.06		65	56,876	0.11		
50–59	87	49,254	0.18		225	50,288	0.45		
60–69	354	70,829	0.50		535	75,278	0.71		
70–79	477	67,098	0.71		737	66,542	1.11		
80–89	783	45,025	1.74		861	38,317	2.25		
≥ 90	449	12,025	3.73		293	7461	3.93		
Total	2194	320,276		0.339 (0.338–0.340)	2716	294,762		0.452 (0.451–0.454)	
Non-Hispanic White	
18–49	22	26,808	0.08		28	22,620	0.12		
50–59	43	21,381	0.20		129	25,264	0.51		
60–69	212	35,859	0.59		350	43,124	0.81		
70–79	305	36,894	0.83		489	39,406	1.24		
80–89	546	26,959	2.03		609	23,671	2.57		
≥ 90	317	7865	4.03		224	4950	4.53		
Total	1445	155,766		0.462 (0.463–0.467)	1829	159,035	1.15	0.581 (0.580–0.583)	
Non-Hispanic Black	
18–49	2	10,381	0.02		4	7152	0.06		
50–59	4	8337	0.05		3	6578	0.05		
60–69	21	10,526	0.20		28	8232	0.34		
70–79	47	9415	0.50		56	7053	0.79		
80–89	47	5616	0.84		55	3769	1.46		
≥ 90	31	1413	2.19		9	653	1.38		
Total	152	45,688		0.136 (0.133–0.137)	155	33,437		0.189 (0.187–0.191)	
Hispanic	
18–49	12	27,630	0.04		27	18,444	0.15		
50–59	33	12,912	0.26		78	11,611	0.67		
60–69	100	14,690	0.68		122	13,922	0.88		
70–79	94	12,769	0.74		148	11,618	1.27		
80–89	130	8074	1.61		143	6767	2.11		
≥ 90	63	1743	3.61		40	1184	3.38		
Total	432	77,818		0.248 (0.246–0.250)	558	63,546		0.374 (0.372–0.377)	
Asian American	
18–49	6	8898	0.07		6	6595	0.09		
50–59	6	5446	0.11		11	5428	0.20		
60–69	12	8288	0.14		31	8341	0.37		
70–79	24	6931	0.35		30	7352	0.41		
80–89	49	3867	1.27		47	3640	1.29		
≥ 90	36	897	4.01		20	613	3.26		
Total	133	34,327		0.166 (0.163–0.169)	145	31,969		0.206 (0.203–0.209)	
a Age and sex standardized to the 2020 US Census.

AS, aortic stenosis.

Rates of severe AS varied by age and sex (Figure 2). In all groups, the rates of AS were low among those < 50 years old and progressively increased with age. In individuals > 90 years of age, severe AS was found in 4.5% of White men, 4.0% of White women, 1.4% of Black men, 2.2% of Black women, 3.4% of Hispanic men, 3.6% of Hispanic women, 3.3% of Asian American men, and 4.0% of Asian American women. Rates of severe AS were higher in men than women across all groups.

Factors associated with severe AS

Age was the strongest risk factor for severe AS [adjusted OR (aOR) = 21.8, 95% CI: 17.8–26.6 for individuals 80 to 89 years old, and aOR = 43.8, 95% 35.5–54.0 for individuals ≥ 90 years old] compared to individuals age < 50 years old (Table 3). Compared to women, men had higher odds of having severe AS (aOR = 1.38, 95% CI: 1.30–1.46). Compared to White race and ethnicity, Black (aOR = 0.44, 95% CI: 0.39–0.50) and Asian American (aOR = 0.47, 95% CI: 0.42–0.53) patients were less likely to have severe AS. Patients with diabetes (aOR = 1.23, 95% CI: 1.15–1.31) were more likely to have severe AS.

Table 3: Factors Associated with severe AS

Factor	Unadjusted odds ratio (95% CI)	P value	Adjusted odds ratio (95% CI) a	P value	
Age group, y	
 18–49	1 (Ref)		1 (Ref)		
 50–59	3.84 (3.09–4.78)	< 0.001	3.56 (2.86–4.44)	< 0.001	
 60–69	7.50 (6.14–9.15)	< 0.001	6.68 (5.46–8.17)	< 0.001	
 70–79	11.26 (9.25–13.70)	< 0.001	9.89 (8.09–12.09)	< 0.001	
 80–89	24.84 (20.46–30.16)	< 0.001	21.78 (17.83–26.61)	< 0.001	
 ≥ 90	48.69 (39.79–59.56)	< 0.001	43.78 (35.52–53.96)	< 0.001	
Sex	
 Female	1 (Ref)		1 (Ref)		
 Male	1.36 (1.28–1.44)	< 0.001	1.38 (1.30–1.46)	< 0.001	
Race and ethnicity					
 Non-Hispanic White	1 (Ref)		1 (Ref)		
 Non-Hispanic Black	0.37 (0.33–0.42)	< 0.001	0.44 (0.39–0.50)	< 0.001	
 Hispanic	0.67 (0.62–0.72)	< 0.001	0.91 (0.84–0.98)	0.01	
 Asian American	0.40 (0.35–0.45)	< 0.001	0.47 (0.42–0.53)	< 0.001	
 Other	0.43 (0.33–0.56)	< 0.001	0.66 (0.51–0.85)	0.002	
Hypertension	
 No	1 (Ref)		1 (Ref)		
 Yes	2.19 (2.05–2.34)	< 0.001	1.05 (0.98–1.13)	0.15	
Diabetes	
 No	1 (Ref)		1 (Ref)		
 Yes	1.44 (1.36–1.53)	< 0.001	1.23 (1.15–1.31)	< 0.001	
Obesity	
 No	1 (Ref)		1 (Ref)		
 Yes	0.77 (0.72–0.83)	< 0.001	0.95 (0.88–1.02)	0.15	
Chronic kidney disease	
 No	1 (Ref)		1 (Ref)		
 Yes	1.88 (1.77–2.00)	< 0.001	0.96 (0.89–1.02)	0.18	
a Multiple variable logistic regression model included the following variables: age, sex, race and ethnicity, hypertension, diabetes, obesity, and chronic kidney disease.

AS, aortic stenosis; Ref, reference.

Discussion

Within a large racially and ethnically diverse population referred for echocardiography, the authors found that 0.8% of patients had severe AS. Across racial and ethnic groups, non-Hispanic White individuals had the highest rate of severe AS. Compared to White patients, non-Hispanic Black (aOR = 0.44, 95% CI: 0.39–0.50) and Asian American (aOR = 0.47, 95% CI: 0.42–0.53) patients had lower likelihood of having severe AS, whereas Hispanic patients (aOR = 0.91, 95% CI: 0.84–0.98) had near similar likelihood. Higher rates of severe AS were observed in men compared with women in all age categories. These findings might account for some of the observed differences in AS treatment rates across sex and racial and ethnic subgroups.

Understanding the burden of AS across diverse racial and ethnic populations is important to ensure the appropriate allocation of public health resources and equitable care for all. Current estimates on AS incidence and rate are based on populations comprised primarily of non-Hispanic White individuals.4 A Swedish study reported an incidence of AS of 11.4 per 100,000 males and 7.1 per 100,000 females.17 In an Icelandic cohort of 685 individuals with echocardiography data, AS was found in 4.3% individuals ≥ 70 years of age.9 In the Norwegian Tromsø Study, which included 3273 participants, AS prevalence was reported to be 0.2% among individuals 50–59 years old and 9.8% in individuals 80–89 years old.18 The prevalence rates reported in these studies are comparable to the rate of AS observed in the present study’s non-Hispanic White cohort. The authors’ finding that the rate of AS increases with age is consistent with these other studies.

Few studies have reported the prevalence of AS in non-Hispanic Black, Hispanic, and Asian American patients in the US. In the Multi-Ethnic Study of Atherosclerosis study, which included 3032 participants who completed echocardiography, 77 participants were found to have AS. They reported the prevalence of AS to be higher in White and Hispanic participants.11 The present study’s findings are consistent with these studies and add to their results by including a much larger cohort of > 600,000 individuals who completed TTE imaging. The cohort presented here is a more diverse cohort with many Hispanic and Asian American individuals.

The population ≥ 65 years of age is anticipated to continue to grow. With age being the strongest risk factor for AS, the population burden of AS will rise. Surgical aortic valve replacement and TAVR are the main treatment options.5 With advancement in TAVR technology resulting in lower rates of complications and new clinical trials supporting expanded indications, there has been a rapid rise in the number of patients treated with TAVR.19,20 Increasing TAVR procedure rates has been associated with decreasing mortality due to AS.7 However, unlike in non-Hispanic White patients, AS mortality rates did not decrease among non-Hispanic Black or Hispanic populations. One hypothesis for this lack of decline is a lower prevalence of AS in the non-Hispanic Black and Hispanic populations.7 The present study found that although the rate of severe AS low in the non-Hispanic Black population, the rate of severe AS in the Hispanic population was not significantly different from that of the non-Hispanic White population, suggesting other factors, such as access to care, may need to be examined.

The National Health Interview Survey evaluated disparities regarding medical care barriers and found that Black and Hispanic individuals face multiple barriers, including long waiting times and a lack of transportation.21 A study using US claims data found a lower rate of the TAVR procedure in ZIP codes with high proportions of individuals of Black race and Hispanic ethnicity,22 suggesting opportunities to develop programs to address barriers to care and improve access.

Study limitations

This study evaluated one of the largest cohorts of adults from diverse racial and ethnic backgrounds who completed echocardiograms, which allowed an estimation of severe AS rate. Nevertheless, the present study has several limitations that should be considered. First, this study was based on patients from an integrated health care system who had completed an echocardiogram and may therefore be biased toward a population with indications for cardiovascular evaluation. However, the diagnosis of AS based on an echocardiogram is more accurate than using administrative claims information or diagnostic codes. Second, individuals included in this study all had insurance and had access to medical care, so the results may not be generalizable to uninsured individuals. Third, individuals with asymptomatic AS never referred for echocardiography may have been missed. Fourth, the terms Asian American, non-Hispanic Black, Hispanic, and non-Hispanic White represent broad groups of cultures and ancestral backgrounds and do not capture the rich diversity and experience inherent to these groups. Fifth, the authors were not able to ascertain if there were racial and ethnic differences in referrals for echocardiography. Sixth, echocardiograms were interpreted by cardiologists with varied training background and levels of experience, the severity of AS was determined by the interpreting cardiologists, and findings were not independently adjudicated by a core laboratory. Finally, any observed association represents a correlation and should not be taken as proof of causality.

Conclusions

In this racially and ethnically diverse cohort, Asian American and non-Hispanic Black patients had lower rates of severe AS compared to White and Hispanic patients. The rate of AS progressively increases with age in all groups, with a higher rate in men compared with women. Future studies are required to evaluate the quality of care and outcomes for patients with AS, with a goal to ensure equal access and outcomes in patients from all backgrounds.

Author Contributions: Contributions of the authors are as follows: Salam Allahwerdy, BS, Benjamin Wessler, MD, Wansu Chen, PhD, and Ming-Sum Lee, MD, PhD—study design, attainment and analysis of data, and drafting and submission of the final manuscript; Fagen Xie, PhD, Botao Zhou, MS, and Yi-Lin Wu, MS—attainment and analysis of data and drafting and submission of the final manuscript.

Conflict of Interests: None declared

Funding: None declared

Data-Sharing Statement: The datasets generated and/or analyzed during the present study are not publicly available due to their being the property of Kaiser Foundation Health Plan, Inc., but are available to interested collaborators in the context of a formal collaboration approved by the Kaiser Permanente Southern California Institutional Review Board for the Protection of Human Subjects.
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