Addressing Disparities in Aortic Stenosis Care for Women, With Julia Grapsa, MD, PhD

Historically, female patients with aortic stenosis are less frequently referred for aortic valve replacement and suffer from higher mortality risks compared to men. In addition to the notoriously lower number of female participants in clinical trials, women with aortic stenosis also go underreported and untreated.1

Previous research has highlighted this disparity, comparing the risk of all-cause mortality between male and female patients with aortic stenosis. The team found that women were substantially less likely to undergo aortic valve replacement, thereby suffering a higher mortality risk when treated conservatively. Despite this, both sexes displayed notable survival benefits from valve replacement.1

Julia Grapsa, MD, PhD, the director for education in echocardiography at Brigham and Women’s Hospital and a faculty member at Harvard Medical School, gave a presentation during the American Heart Association’s Scientific Sessions 2025 in New Orleans, Louisiana, addressing the disparities faced by female patients, as well as how clinicians can address them.2

For additional insight, the editorial team at HCPLive spoke with Grapsa in the following Q&A:

HCPLive: What disparities exist in aortic stenosis treatment?

Grapsa: Starting from diagnosis of aortic stenosis in women, they present quite differently than men. So, for example, women may complain of shortness of breath or chest pain more often than men. The heart also remodels in a different way in women than in men. For example, we are not going to see heavy calcification in a woman: it will be more fibrocalcific aortic stenosis, rather than the heavy calcific aortic stenosis that we see in men. When taking into account the aortic stenosis in women, especially because women are multitasking and have a huge responsibility daily, it may be underdiagnosed or non-diagnosed for years. We may have women who explain that they have shortness of breath or minimal symptoms like palpitations, and they may not get a prompt echo referral.

HCPLive: How is your presentation addressing these disparities?

Grapsa:Firstly, we’re discussing that women present differently than men, and second, that they are often underdiagnosed, because we saw in major centers that there was a delay to get an echo when compared to men. And a delay in diagnosis means delay in the treatment. Women also tend to present with what we call paradoxical low flow log gradient, which is when the ventricle gets impaired in the long term, or with significant diastolic impairment, and therefore delayed treatment will affect also the mortality outcomes. So eventually, if we delay treatment for too long, the mortality outcomes are higher.

As we know, another important parameter is that, up to now, not many women have been recruited for valve trials or cardiology trials in general. And our first trial, the SMART trial, was dedicated to women's anatomy and physiology, so it addresses small annuli that we see in women. And then we had the REAL trial that was dedicated to women, and they both proved, in a way, that treating women with TAVI promptly benefits outcomes and rates of hospitalization.

HCPLive: What progress has been made in recent years towards addressing and resolving these disparities?

Grapsa: We have gone deeply into addressing awareness, starting from the community: the awareness of primary care professionals in referring women for an echo promptly, and to refer them to specialty valve centers to get treated. When, for example, we diagnose severe, even asymptomatic, aortic stenosis, the patient needs to be referred to a specialty center immediately. And then we went a step further, and we have sex differences in the way we measure in echo, or, for example, in CT units. We know now that the CT calcium score is very different for women than for men. And of course, the even the LV stroke volume the new guidelines they gave it 32 ml per meter squared for women and 40 ml per meter squared in men. This difference did not exist before, so it's something novel. And of course, then we will go a step further and say that we need to treat women differently, given that they have smaller anatomies and a different physiology than men. And based on that and the differences we see between balloon expandable versus self-expandable valves or the rate of pacemakers. Then, when we see a woman in the clinic, we can go from diagnosis and sex differences in measurements up to the differences in valve selection and durability and especially depending on the underage and the functional capacity to aim for a long term prognosis and management plan dedicated and personalized for them.

HCPLive: On an individual level, how can clinicians address the remaining disparities in cardiovascular treatment for women?

Grapsa: As I said, awareness is a key word. Everybody needs to be aware that even a woman who presents with minor symptoms may have significant valvular heart disease. And then the next level is good communication with the patient. Last year, we published a small booklet for aortic stenosis in women, and we have a questionnaire that they can fill in and say how they're keeping in everyday household work and exercise, checking if they are managing their everyday duties. So going into depth, spending time with our patient and asking them if they can do today what they could do last year is key the good communication between health professionals and patients to get the diagnosis promptly rather than late.

Editor’s Note: Grapsa reports no relevant disclosures.

References

1. Paquin A, Abdoun K, Bienjonetti-Boudreau D, Pibarot P, Clavel MA. Sex-Specific Outcomes in Patients With Aortic Stenosis and Reduced Ejection Fraction. Can J Cardiol. 2025;41(11):2232-2240. doi:10.1016/j.cjca.2025.07.012

2. Grapsa J. Transforming Aortic Stenosis Care with Medtronic TAVR for Women and lower risk patients. Presented at the American Heart Association’s Scientific Sessions 2025. New Orleans, Louisiana. November 8-10, 2025.