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. 2022 Jun 9;9(5):2851–2861. doi: 10.1002/ehf2.13957

Temporal trends in incidence, prevalence, and death of aortic stenosis in Korea: a nationwide population‐based study

Shin Yi Jang 1, Sung‐Ji Park 1,✉, Eun Kyoung Kim 1, Seung Woo Park 1
PMCID: PMC9715794  PMID: 35686340

Abstract

Aims

We aim to determine the temporal trends of incidence, prevalence, and death of aortic stenosis (AS, I35.0) in an East Asian population.

Methods and results

Data for 3773 patients who were newly diagnosed with AS from 2006 through 2017 were extracted from the National Health Insurance Service in Korea. The age‐standardized incidence rate, prevalence rate, and death rate, survival rate (SR), and death risk of AS were calculated. Overall, the mean (standard deviation) age of AS patients was 69.9 (15.3) years [66.2 (15.7) years for men and 72.7 (14.4) years for women (P = 0.007)], and the proportion of men was 42.7%. The proportion of AS patients ≥60 years old was 80% (71.8% in men and 86% in women, P < 0.001). The proportion of patients who died of AS was 36.4% during the period from 2006 through 2017. The most common causes of death were disease of the circulatory system. The age‐standardized incidence, prevalence, and death rates in 2017 were 0.85, 2.79, and 0.58 persons per 100 000 persons, respectively. The 10 year SR was 49.2%. The higher adjusted HRs [95% CI] for AS were observed in 70‐ to 79‐year‐old people (9.08 [1.27, 64.7], P = 0.027), in individuals 80 years of age or older (22.7 [3.18, 161.9], P = 0.001), in men (1.46 [1.31, 1.63], P < 0.001), among the middle socioeconomic group (1.19 [1.03, 1.37], P = 0.016), among the lower income levels (1.32 [1.17, 1.49], P < 0.001), in those with myocardial infarction (1.57 [1.16, 2.13], P = 0.003), with heart failure (1.63 [1.44, 1.85], P < 0.001), with ischaemic stroke (3.26 [1.20, 8.85], P = 0.015), with haemorrhagic stroke (2.51 [1.94, 3.25], P = 0.02), with chronic kidney disease (2.51 [1.94, 3.25], P < 0.001), and with malignant neoplasm (2.33 [1.64, 3.31], P < 0.001).

Conclusions

The proportion of AS at age ≥60 years was 80%. For AS, the age‐standardized incidence rates were steady, prevalence rates increased, and death rates decreased by year over a decade. The 10 year SR of AS was about 50%. The most common cause of death in AS was disease of the circulatory system. Given the progressively higher incidence of AS with age continued efforts are required to increase awareness regarding AS‐related symptoms and potential complications in aged people.

Keywords: Aortic stenosis, Prevalence, Incidence, Death rate, Survival rates, Death risk, Cause of death

Introduction

Aortic stenosis (AS) is a common form of heart valve disease and the most common reason for valve replacement. The prevalence of AS has been estimated to be 0.3% to 0.5% in the general population and to be markedly higher in the elderly, with an estimated prevalence of 2% to 7% in individuals >65 years of age. 1 , 2 The aging of Western countries can be expected to result in an increased burden of AS. 3 However, temporal trends regarding prevalence, incidence, and death of AS have not been well established in East Asian populations. Our group found that the overall age‐standardized cumulative prevalence of non‐rheumatic valvular heart disease increased between 2006 and 2011, especially in patients older than 65 years. 4 Therefore, temporal trends of prevalence, incidence, and prognosis of AS should be reassessed due to the rapidly aging population of Korea. In this study, we assessed the age‐standardized incidence, age‐standardized prevalence, age‐standardized death rate, survival rate (SR), causes of death, and death risk for AS using Korean National Health Insurance Service (KNHIS) data from 2006 through 2017.

Methods

Data source: Korean National Health Insurance Service database

The universal coverage health insurance system in Korea for all citizens was initiated in 1963, based on the National Medical Insurance Act, and universal healthcare coverage was achieved in 1989. The KNHIS database for health insurance subscribers and Medicare recipients excluding foreigners consists of the following four databases: (i) a qualification database including age, sex, type of subscription, and income rank; (ii) a medical check‐up database including health examination data and lifetime transition period medical check‐ups at 40 and 66 years of age; (iii) a medical institution database; and (iv) a treatment database including the type of disease, the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD‐10) code, and prescriptions. The treatment database has four categories: medicine, dentistry, Oriental medicine, and pharmacy, of which we examined only used the medicine data. We used variables from the qualifications database in conjunction with treatment. 5 , 6 , 7

Diagnosis of aortic stenosis

Newly diagnosed AS data were collected from the KNHIS records from 2006 through 2017. The data consisted of primary diagnoses related to AS according to ICD‐10 code (I35.0). Newly diagnosed AS was defined as an operational definition using ICD‐10 code (I35.0). In order to include only newly diagnosed AS patients from the KNHIS database, AS diagnosed before the corresponding year were excluded.

Definitions of variables

Age was categorized as 0–9 years, 10–19 years, 20–29 years, 30–39 years, 40–49 years, 50–59 years, 60–69 years, 70–79 years, and 80 years or older. We defined groups by income level from the national health insurance premium as a socioeconomic factor. Income levels were categorized as upper, medium, and lower. According to the household insurance premium, members of the same household are included in the same income category according to employee‐insured or self‐employed.

Co‐morbidities

We defined co‐morbidities based on primary and secondary diagnoses: hypertension (ICD‐10 I10, I11, I12, I13, I15); diabetes mellitus (ICD‐10 E10, E11 E12, E13, E14); dyslipidaemia (ICD‐10 E78); myocardial infarction (ICD‐10 I21, I22, I25.2); heart failure (ICD‐10 I11.1, I50, I97.1); atrial fibrillation (ICD‐10 I48.0); ischaemic stroke (ICD‐10 I63, I64); haemorrhagic stroke (ICD‐10 I60, I61, I62); transient ischaemic attack (ICD‐10 G45); chronic kidney disease (CKD) (ICD‐10 N18, N19); and malignant neoplasm (ICD‐10 C00‐C97).

Death data

We used death data for the Korean population from 2006 through 2018. The validity of this data is based on requirements of Korean citizens to submit (i) a death declaration and (ii) a death certificate or a corpse optometry report by a medical doctor to the town office of the deceased's place of residence or an area prescribed by law within 1 month of death, and the submission must be completed by a direct family member or a person prescribed by law. The death declaration must include the following information: (i) the deceased's name; gender; resident registration number; address; death date and time; place of death; cause of death; death type such as that due to disease or accident; if accident, type of accident, accident date, and place of accident; nationality; and marriage status; (ii) the reporter's name, identification number, relationship with the dead, and contact information; and (iii) the submitter's name and identification number. Among the aforementioned information, we received only the cause and date of death from the Korea Statistics Promotion Institute in accordance with official procedures. 6

Cause of death

We evaluated primary causes of death: certain infections and parasitic diseases (ICD‐10 A00‐B99); malignant neoplasm (ICD‐10 C00‐C97); benign neoplasm (ICD‐10 D00‐D48) and diseases of the blood and blood‐forming organs and certain disorders involving the immune mechanism (ICD‐10 D50‐D89); endocrine, nutritional, and metabolic diseases (ICD‐10 E00‐E90); mental and behavioural disorders (ICD‐10 F01‐F99); diseases of the nervous system (ICD‐10 G00‐G98); diseases of the circulatory system (ICD‐10 I00‐I99); diseases of the respiratory system (ICD‐10 J00‐J98); diseases of the digestive system (ICD‐10 K00‐K92); diseases of the skin and subcutaneous tissue (ICD‐10 L00‐L99); diseases of the musculoskeletal system and connective tissue (ICD‐10 M00‐M99); diseases of the genitourinary system (ICD‐10 N00‐N99); congenital malformations, deformations, and chromosomal abnormalities (ICD‐10 Q00‐Q99); symptoms, signs, and abnormal clinical and laboratory findings not elsewhere classified (ICD‐10 R00‐R99); injury, poisoning, and certain other consequences of external causes (ICD‐10 S00‐T98); and not provided.

Statistical methods

Trend tests by year, age group, sex, income level, co‐morbidities, death, and cause of death were analysed using the Cochran‐Armitage Trend test. Differences in characteristics by sex were analysed using Student's t‐test for continuous variables and the χ 2 test for categorical variables. The age‐standardized incidence, prevalence, and death rates of AS were calculated by the direct method using beneficiaries of health insurance from the Korean National Health Insurance Statistical Yearbook from 2006 through 2017 and the estimated Korean population in 2015 as a reference. 4 , 7 , 8 The Kaplan–Meier method was used with log‐rank tests to compare survival among patients with AS by sex and age group. Simple and multiple Cox proportional hazards analyses were carried out using the variables age, sex, income level, and co‐morbidities. All analyses were performed using SAS software (version 9.4 for Windows; SAS Institute Inc., Cary, NC, USA). A two‐tailed P value <0.05 was considered statistically significant for all comparisons.

Results

Among 3773 newly diagnosed AS, the proportions by year from 2006 to 2017 were 6.57%, 6.79%, 7.55%, 6.57%, 6.49%, 9.22%, 8.40%, 8.75%, 8.53%, 9.22%, 11.29%, and 10.6%, respectively. Table 1 showed the proportion of the variables for each year; the distribution of age group, income level, dyslipidaemia, heart failure, ischaemic stroke, CKD, and death by year was statistically significant (P for trend <0.05).

Table 1.

Characteristics of the patients with newly diagnosed aortic stenosis (AS) in Korea between 2006 and 2017

Variables 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 P‐value*
Newly diagnosed AS, numbers 248 256 285 248 245 348 317 330 322 348 426 400 ‐
Age, group <0.001
0–9, % 2.02 0.78 2.46 0.81 1.22 1.15 0.00 1.21 0.93 0.86 0.23 0.50
10–19, % 0.40 1.56 2.11 0.81 1.22 1.44 0.32 0.61 0.00 0.29 0.70 1.25
20–29, % 0.81 0.78 1.05 0.00 0.41 0.86 0.32 0.30 0.00 0.86 0.23 0.25
30–39, % 3.63 3.52 3.51 2.02 0.82 1.15 0.63 0.61 0.31 0.86 0.23 1.00
40–49, % 6.85 7.42 6.67 5.24 4.49 4.89 4.73 2.12 3.73 3.45 3.05 4.00
50–59, % 14.9 9.38 14.7 14.9 13.5 14.1 11.4 11.2 12.4 11.2 7.75 9.00
60–69, % 21.8 23.8 23.5 19.8 24.1 20.7 20.2 19.4 17.1 16.7 17.6 18.3
70–79, % 31.1 34.4 26.7 32.3 31.8 27.6 34.4 34.2 37.3 34.8 39.2 25.8
≥80, % 18.6 18.4 19.3 24.2 22.5 28.2 28.1 30.3 28.3 31.0 31.0 40.0
Sex, % 0.464
Male 39.5 43.0 42.5 42.7 38.4 47.4 41.0 44.9 42.9 40.8 43.7 43.8
Female 60.5 57.0 57.5 57.3 61.6 52.6 59.0 55.1 57.1 59.2 56.3 56.2
Income level 0.011
Upper 43.2 43.0 47.7 46.8 49.4 47.7 52.1 47.3 53.1 49.4 50.2 49.0
Middle 23.4 22.3 23.9 24.2 21.2 18.7 25.2 26.1 21.1 21.6 22.1 22.5
Lower 33.5 34.8 28.4 29.0 29.4 33.6 22.7 26.7 25.8 29.0 27.7 28.5
Co‐morbidities, %
Hypertension 40.3 41.5 37.2 46.3 44.5 38.4 38.5 48.4 41.8 44.1 42.1 40.1 0.595
Diabetes mellitus 9.44 7.11 7.06 11.0 11.3 9.61 9.06 12.0 10.8 11.3 9.78 9.36 0.246
Dyslipidaemia 8.15 9.49 11.2 10.6 15.1 14.4 13.6 15.4 16.8 14.9 12.2 17.4 <0.001
Myocardial infarction 3.00 1.98 1.12 2.85 1.68 1.80 1.62 2.52 1.27 2.13 2.69 2.41 0.769
Heart failure 19.3 13.8 14.5 16.3 11.3 16.8 21.7 13.8 19.9 26.4 18.3 21.7 <0.001
Atrial fibrillation 0.00 0.00 0.00 0.00 0.00 14.1 12.9 11.9 11.3 12.7 13.2 12.5 <0.001
Ischaemic stroke 3.00 2.37 1.86 2.85 3.78 1.50 1.94 2.20 2.22 1.82 1.22 1.07 0.039
Haemorrhagic stroke 0.00 0.40 0.00 0.41 0.42 0.00 0.32 0.63 0.00 0.00 0.00 0.00 0.326
Transient ischaemic attack 0.00 0.40 0.00 0.41 0.42 0.30 0.00 0.00 0.00 0.30 0.00 0.00 0.285
Chronic kidney disease 2.15 1.58 1.49 1.22 1.26 1.80 2.59 3.77 1.9 4.86 4.89 2.94 <0.001
Malignancy neoplasm 2.15 0.40 0.37 0.81 0.00 2.10 1.29 1.26 1.27 0.91 1.47 1.34 0.465
Death, % 53.6 50.0 48.1 45.6 41.2 42.2 39.4 35.8 30.8 27.0 25.6 17.5 <0.001
Number of death 133 128 137 113 101 147 125 118 99 94 109 70 ‐
Age, group <0.001
0–9, % 0.00 0.00 0.73 0.00 0.00 0.68 0.00 0.00 0.00 0.00 0.00 0.00
10–19, % 0.00 0.00 0.00 0.00 0.00 0.68 0.00 0.00 0.00 0.00 0.00 0.00
20–29, % 0.00 0.00 0.00 0.00 0.00 0.68 0.00 0.00 0.00 0.00 0.00 0.00
30–39, % 1.50 0.78 0.73 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
40–49, % 2.26 1.56 1.46 0.88 0.99 1.36 3.20 0.85 0.00 1.06 0.00 0.00
50–59, % 6.02 0.78 3.65 3.54 2.97 4.08 2.40 0.85 2.02 4.26 6.42 0.00
60–69, % 15.8 18.0 17.5 11.5 16.8 9.5 6.4 8.5 10.1 13.8 7.34 8.57
70–79, % 39.8 47.7 37.2 34.5 31.7 32.0 33.6 35.6 36.4 29.8 33.0 24.3
≥80, % 34.6 31.3 38.7 49.6 47.5 51.0 54.4 54.2 51.5 51.1 53.2 67.1
Sex, male, % 39.8 39.8 34.3 36.3 38.6 44.9 43.2 49.2 40.4 40.4 47.7 42.9 0.456
Cause of death 0.917
Certain infections and parasitic diseases (A00‐B99) 1.50 1.56 3.65 1.77 1.98 2.04 0.00 1.69 2.02 0.00 1.83 0.00
Malignant neoplasm (C00‐C97) 13.5 7.80 10.9 13.3 8.91 7.50 11.2 14.4 9.10 11.7 7.30 2.90
Neoplasm (D00‐D48) and diseases of the blood and blood‐forming organs and certain disorders involving the immune mechanism (D50‐D89) 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.92 1.43
Endocrine, nutritional, and metabolic diseases (E00‐E90) 3.76 5.47 2.92 3.54 0.00 3.40 4.80 2.54 1.01 2.13 4.59 2.86
Mental and behavioural disorders (F01‐F99) 0.00 0.78 2.92 1.77 0.99 0.68 0.80 0.00 1.01 0.00 0.00 0.00
Diseases of the nervous system (G00‐G98) 0.75 0.78 0.73 2.65 2.97 1.36 0.80 0.85 0.00 2.13 0.00 0.00
Diseases of the circulatory system (I00‐I99) 47.4 47.7 52.6 39.8 52.5 51.7 39.2 39.0 47.5 53.2 42.2 27.1
Diseases of the respiratory system (J00‐J98) 7.52 7.03 5.84 8.85 4.95 7.48 9.60 5.93 12.1 3.19 4.59 5.71
Diseases of the digestive system (K00‐K92) 0.75 2.34 1.46 3.54 1.98 3.40 4.00 5.93 2.02 3.19 1.83 4.29
Diseases of the skin and subcutaneous tissue (L00‐L98) 0.75 0.00 0.00 0.00 0.00 0.00 0.80 0.85 0.00 0.00 0.00 0.00
Diseases of the musculoskeletal system and connective tissue (M00‐M99) 0.00 0.78 0.73 0.88 0.99 0.00 0.00 0.00 0.00 0.00 0.00 1.43
Diseases of the genitourinary system (N00‐N98) 1.50 3.13 3.65 5.31 1.98 3.40 4.80 4.24 5.05 6.38 2.75 1.43
Congenital malformation, deformations and chromosomal abnormalities (Q00‐Q99) 0.00 0.00 0.73 0.00 0.00 1.36 0.00 0.00 0.00 0.00 0.00 0.00
Symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified (R00‐R99) 12.0 9.38 7.30 7.08 5.94 4.76 8.00 5.93 5.05 2.13 5.50 1.43
Injury, poisoning, and certain other consequences of external causes (S00‐T98) 3.01 1.56 1.46 1.77 2.97 2.72 3.20 4.24 3.03 0.00 3.67 1.43
Not provided 7.52 11.7 5.11 9.73 13.9 10.2 12.8 14.4 12.1 16.0 24.8 50.0
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Bold P‐values identify statistically significant values.

*

P for trend by year and each variables.

The mean age of AS patients was 69.9 (±15.3) years; 66.2 (±15.7) years for men and 72.7 (±14.4) years for women (P < 0.01). The proportion of AS patients ≥60 years old was 80% (71.8% in men and 86% in women, P < 0.001). The proportions of co‐morbidities with AS were 40.3% with hypertension, 9.46% with diabetes mellitus, 13.0% with dyslipidaemia, 2.01% with myocardial infarction, 17.4% with heart failure, 8.06% with atrial fibrillation, 1.96% with ischaemic stroke, 0.16% with haemorrhagic stroke, 0.13% with transient ischaemic attack, 2.60% with CKD, and 1.11% with malignant neoplasm. More AS patients were in the upper socioeconomic group than in the middle or lower group. The proportion of patients who died of AS was 36.4%. Diseases of the circulatory system comprised the highest cause of death among AS patients overall (45.6%), followed by malignant neoplasm (10.1%) (Table 2 ).

Table 2.

The distribution of general characteristics and causes of death by sex among individuals with newly diagnosed aortic stenosis from 2006 through 2017 (n = 3773)

Variables Total Male Female P‐value*
n = 3773 n = 1613 n = 2160
mean ± SD or number (percentage)
Age, years, mean (±SD) 69.9 ± 15.3 66.2 ± 15.7 72.7 ± 14.4 0.007
0–9 36 (0.95) 18 (1.12) 18 (0.83) <0.001
10–19 33 (0.87) 25 (1.55) 8 (0.37)
20–29 18 (0.48) 10 (0.62) 8 (0.37)
30–39 52 (1.38) 24 (1.49) 28 (1.30)
40–49 171 (4.53) 96 (2.54) 75 (3.47)
50–59 443 (11.7) 281 (17.4) 162 (7.5)
60–69 751 (19.9) 378 (23.4) 373 (17.2)
70–79 1228 (32.5) 492 (30.5) 736 (34.0)
80+ 1041 (27.6) 289 (17.9) 752 (34.8)
Sex, mem 1613 (42.7) 1613 (100) 0 (0.00) ‐
Income level a 0.127
Upper 1880 (48.5) 807 (50.0) 1023 (47.4)
Middle 853 (22.6) 367 (22.8) 486 (22.5)
Lower 1090 (28.9) 439 (27.2) 651 (30.1)
Co‐morbidities
Hypertension 1519 (40.3) 602 (37.3) 917 (42.4) 0.019
Diabetes mellitus 357 (9.46) 153 (9.49) 204 (9.44) 0.693
Dyslipidaemia 491 (13.0) 200 (12.4) 291 (13.4) 0.579
Myocardial infarction 76 (2.01) 36 (2.23) 40 (1.85) 0.327
Heart failure 659 (17.4) 250 (15.5) 409 (18.9) 0.023
Atrial fibrillation 304 (8.06) 140 (8.68) 164 (7.59) 0.123
Ischaemic stroke 74 (1.96) 28 (1.74) 46 (2.13) 0.476
Haemorrhagic stroke 6 (0.16) 2 (0.12) 4 (0.19) 0.677
Transient ischaemic attack 5 (0.13) 4 (0.24) 1 (0.04) 0.083
Chronic kidney disease 98 (2.60) 54 (3.35) 44 (2.04) 0.007
Malignant neoplasm 42 (1.11) 22 (1.36) 20 (0.93) 0.165
Death 1374 (36.4) 576 (35.7) 798 (36.9) 0.435
Cause of death, n = 1374 <0.001
Certain infections and parasitic diseases (A00‐B99) 22 (1.60) 3 (0.52) 19 (2.38)
Malignant neoplasm (C00‐C97) 139 (10.1) 83 (14.5) 56 (7.02)
Neoplasm (D00‐D48) and diseases of the blood and blood‐forming organs and certain disorders involving the immune mechanism (D50‐D89) 2 (0.15) 2 (0.34) 0 (0.00)
Endocrine, nutritional, and metabolic diseases (E00‐E90) 44 (3.20) 17 (2.95) 27 (3.38)
Mental and behavioural disorders (F01‐F99) 11 (0.80) 3 (0.52) 8 (1.00)
Diseases of the nervous system (G00‐G98) 15 (1.09) 5 (0.87) 10 (1.25)
Diseases of the circulatory system (I00‐I99) 627 (45.6) 241 (41.8) 386 (48.4)
Diseases of the respiratory system (J00‐J98) 96 (6.99) 49 (8.51) 47 (5.89)
Diseases of the digestive system (K00‐K92) 39 (2.84) 15 (2.60) 24 (3.01)
Diseases of the skin and subcutaneous tissue (L00‐L98) 3 (0.22) 0 (0.00) 3 (0.38)
Diseases of the musculoskeletal system and connective tissue (M00‐M99) 5 (0.36) 1 (0.17) 4 (0.50)
Diseases of the genitourinary system (N00‐N98) 50 (3.64) 22 (3.81) 28 (3.51)
Congenital malformation, deformations and chromosomal abnormalities (Q00‐Q99) 3 (0.22) 2 (0.35) 1 (0.13)
Symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified (R00‐R99) 90 (6.55) 29 (5.03) 61 (7.64)
Injury, poisoning, and certain other consequences of external causes (S00‐T98) 34 (2.47) 18 (3.13) 16 (2.01)
Not provided 194 (14.1) 86 (14.9) 108 (13.5)
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SD, standard deviation.

Bold P‐values identify statistically significant values.

*

Student's t‐test or χ 2‐test.

a

Income level according to the national health insurance premium.

The adjusted hazard ratio (HR) for AS was 9.08 [95% confidence interval (CI) 1.27, 64.7] among individuals 70–79 years old, 22.7 (95% CI 3.18, 161.9) among those 80 years or older, 1.46 (95% CI 1.31, 1.63) among men, 1.19 (95% CI 1.03, 1.37) among the middle socioeconomic group, 1.32 (95% CI 1.17, 1.49) among the lower socioeconomic group, 0.86 (95% CI 0.77, 0.97) among those with hypertension, 0.67 (95% CI 0.56, 0.81) among those with dyslipidaemia, 1.57 (95% CI 1.16, 2.13) among those with myocardial infarction, 1.63 (95% CI 1.44, 1.85) among those with heart failure, 1.52 (95% CI 1.08, 2.13) among those with ischaemic stroke, 3.26 (95% CI 1.20, 8.85) among those with haemorrhagic stroke, 2.51 (95% CI 1.94, 3.25) among those with CKD, and 2.33 (95% CI 1.64, 3.31) among those with malignant neoplasm (Table 3 ).

Table 3.

Death risk from aortic stenosis

Variables Crude hazard ratio (HR) and 95% CI P‐value Adjusted HR and 95% CI* P‐value
Age group, years
0–9 0.98 (0.08, 10.8) 0.989 ‐ ‐
10–19 0.55 (0.03, 8.87) 0.677 ‐ ‐
20–29 1.00 ‐ 1.00 ‐
30–39 0.94 (0.10, 8.45) 0.880 1.07 (0.11, 9.61) 0.951
40–49 1.48 (0.19, 11.1) 0.534 1.48 (0.19, 11.1) 0.701
50–59 1.39 (0.19, 10.1) 0.485 1.53 (0.27, 11.1) 0.672
60–69 3.48 (0.48, 2.48) 0.108 4.09 (0.57, 29.2) 0.160
70–79 7.65 (1.07, 54.4) 0.015 9.08 (1.27, 64.7) 0.027
80+ 18.9 (2.66, 134.8) <0.001 22.7 (3.18, 161.9) 0.001
Sex, male vs. female 0.97 (0.87, 1.09) 0.406 1.46 (1.31, 1.63) <0.001
Income level†
Upper 1.00 1.00
Middle 0.94 (0.81, 1.08) 0.269 1.19 (1.03, 1.37) 0.016
Lower 1.30 (1.16, 1.47) <0.001 1.32 (1.17, 1.49) <0.001
Hypertension 0.96 (0.86, 1.07) 0.536 0.86 (0.77, 0.97) 0.012
Diabetes mellitus 1.18 (0.99, 1.40) 0.051 1.17 (0.99, 1.39) 0.065
Dyslipidaemia 0.64 (0.53, 0.76) <0.001 0.67 (0.56, 0.81) <0.001
Myocardial infarction 2.17 (1.61, 2.92) <0.001 1.57 (1.16, 2.13) 0.003
Heart failure 2.04 (1.81, 2.31) <0.001 1.63 (1.44, 1.85) <0.001
Atrial fibrillation 1.27 (1.04, 1.54) 0.016 1.00 (0.82, 1.22) 0.972
Ischaemic stroke 1.29 (0.92, 1.81) 0.128 1.52 (1.08, 2.13) 0.015
Haemorrhagic stroke 1.59 (0.59, 4.25) 0.350 3.26 (1.20, 8.85) 0.020
Transient ischaemic attack 0.78 (0.19, 3.13) 0.730 0.74 (0.18, 2.97) 0.670
Chronic kidney disease 2.90 (2.25, 3.75) <0.001 2.51 (1.94, 3.25) <0.001
Malignant neoplasm 3.19 (2.26, 4.51) <0.001 2.33 (1.64, 3.31) <0.001
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CI, confidence interval.

Bold P‐values identify statistically significant values.

*

Estimated by Cox proportional hazard model analysis using the variables indicated in the table.

Overall, the age‐standardized incidence of AS was 0.88 persons per 100 000 in 2006 and 0.80 persons per 100 000 in 2017 (Figure 1 and Supporting Information, Table S1 ). The age‐standardized prevalence of AS increased from 1.91 persons per 100 000 persons in 2006 to 2.79 persons per 100 000 persons in 2017 (Figure 1 and Supporting Information, Table S2 ). The age‐standardized death rates of AS was 0.58 persons per 100 000 in 2006 and 0.16 persons per 100 000 in 2017 (Figure 1 and Supporting Information, Table S3 ).

Figure 1.

Figure 1

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Distribution of aortic stenosis (AS) by sex‐ and age‐standardized incidence, prevalence, and death rate of AS overall and by sex, age group, and year per 100, 000 persons between 2006 and 2017. (A) Prevalence: the number of AS patients by sex and age‐standardized prevalence of AS overall (middle) and by sex (male: lower; female: upper). (B) Age‐standardized prevalence of AS by year and age group over 40 years per 100 000 persons between 2006 and 2017. (C) Incidence: the number of AS patients by sex and age‐standardized incidence of AS overall (middle) and by sex (male: lower; female: upper). (D) Age‐standardized incidence of AS by year and age group over 40 years per 100 000 persons between 2006 and 2017. (E) Death rate: the number of AS patients by sex and age‐standardized death rate of AS overall (middle) and by sex (male: lower; female: upper). (F) Age‐standardized death of AS by year and age group over 40 years per 100 000 persons between 2006 and 2017.

The 1, 3, 5, and 10 year SRs of AS were 86.4%, 75.1%, 67.0%, and 49.2%, respectively. The 1, 3, 5, and 10 year SRs by sex were 86.3%, 75.1%, 67.4%, and 48.3%, respectively, among women and 86.6%, 75.0%, 66.6%, and 50.3% among men [P = non‐significant (NS)]. The respective 1, 3, 5, and 10 year SRs were 93.9%, 87.6%, 82.9%, and 68.6%, respectively, in the 60 to 69 year age group; 87.0%, 76.9%, 67.2%, and 40.2% in the 70 to 79 year age group; and 74.0%, 51.2%, 37.0%, and 9.0% in the age group 80 years and older (P < 0.001) (Figure 2 and Supporting Information, Table S4 ).

Figure 2.

Figure 2

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Survival curve of aortic stenosis (AS) in Korea. (A) AS survival rate overall, AS survival rate by sex (P = 0.702), and (B) AS survival rates by age group (P < 0.001).

Discussion

The major findings of this study were as follows. (i) Four‐fifths of AS patients were ≥60 years old. (ii) The adjusted HR for AS was significantly higher in individuals 70–79 years or older; men; the relatively lower income level; and those with myocardial infarction, heart failure, ischaemic stroke, haemorrhagic stroke, CKD, or malignant neoplasm. (iii) The 10 year SR of AS was about 50%. (iv) We showed steady age‐standardized incidence rates, increased age‐standardized prevalence rates, and decreased age‐standardized death rates of AS over the decade of study. (v) The most common cause of death in AS was disease of the circulatory system.

Among all AS patients, from infants to the elderly, 80% were in their 60s and older. Most AS patients in Korea are elderly, as in Western populations. Interestingly, in this study, there were large proportions of AS patients among men in their 50s and older and among women in their 60s and older. It is difficult to explain why the distribution differed by gender. However, the economic participation rate of individuals in their 50s increased from 54.7% in 2006 to 62.2% in 2014 among women and from 85.4% in 2006 to 89.4% in 2014 among men in Korea. 9 Generally, occupational class was divided into non‐manual and manual work. 10 Health examinations are conducted once every 2 years for non‐manual workers and once every year for manual workers following occupational safety and health laws in Korea. 11 , 12 Therefore, men older than 50 have a greater chances than women to be diagnosed with AS through echocardiography during health checkups conducted at workplaces. We believe that the larger proportion of AS among women in their 60s and older in our study is due to increasing opportunities for contact with health services due to the health examination that has been offered by the KNHIS at the age of 66 years since 2007. The proportion of elderly patients undergoing this health examination has increased from approximately 51% in 2007 to 76% in 2011. 4 , 13 Consequently, the proportion of individuals diagnosed with AS has increased with age. We believe that these findings indicate a predominance of degenerative valve diseases in Korea. Our findings are similar to AS data from the National Heart, Lung, and Blood Institute study of the general United States population 14 and from a population‐based cohort Tromoso AS study conducted over a 14 year span in Norway. 15

The adjusted HR for AS increased with age and male sex. These results correspond with those in a population‐based study from Toronto, Canada, that included 1 120 208 elderly AS patients, among whom HR was significantly higher than in younger individuals. 16 For men, the HR for AS was significantly higher than that for women, as Korean men have a higher mortality rate and lower life expectancy than do Korean women. 7 , 17 , 18 We also observed significantly higher risk of death due to AS among individuals of lower income, demonstrating the effects of income inequality on the outcomes of cardiovascular disease. 7 , 19 In general, relatively higher income levels tend to have higher SRs for any cause of death in the same age group because they have access to more advanced medical care and better life conditions. Therefore, we analysed HR after adjusting for co‐morbidities because the occurrence of co‐morbidities may not be related to higher income levels. The adjusted HR for AS significantly increased with myocardial infarction, heart failure, ischaemic stroke, haemorrhagic stroke, CKD, and malignant neoplasm. In addition, the adjusted HR for AS significantly decreased with hypertension and dyslipidaemia. The higher HR of myocardial infarction, heart failure, and stroke is in line with the main cause of death, which was disease of the circulatory system in this study. CKD is identified in an increasing number of cases worldwide and is associated with morbidity and mortality. 20 , 21 We think that the mechanism of increased cardiovascular disease in valvular heart disease is due to the effect of accumulating cardiovascular risk factors over time. Malignant neoplasm showed the highest HR for AS among co‐morbidities, which was consistent with the report that the primary cause of death in Korea is malignant neoplasm. 7 , 18 The relatively lower HR of the AS patients with hypertension or dyslipidaemia was attributed to more frequent medical treatment in such patients rather than to the actual co‐morbidity. In this study, we did not show the distribution of anti‐hypertensive medication and lipid‐lowering agents due to KNHIS data limitation.

In this study, the 1, 3, 5, and 10 year SRs of AS were 86.4%, 75.1%, 67.0%, and 49.2%, respectively. We cannot directly compare our 10 year SR data because no other studies have reported 10 year SR by sex and age group using a nationwide database. Nevertheless, the 1 and 3 year SRs of 519 severe AS patients in Japan were 86% and 70%, respectively. 22 These results are consistent with our 1 and 3 year SRs. The 10 year SR of 13 220 non‐congenital AS patients in Scotland was about 50%. 23 However, 1, 2, 3, 4, and 6 year SRs for very severe AS in Austria from 1995 to 2008 were 64%, 36%, 25%, 12%, and 3%, respectively, while 1, 3, and 5 year mortality for very severe elderly AS were 21%, 43%, and 56% in Korea. 24 This indicates that the increasing severity of AS with age influences SR. Furthermore, although the distribution of AS by sex showed higher proportions of AS in women than in men, 15 , 16 , 25 , 26 SR in the present study did not significantly differ by sex in individuals with AS. We think that the increase in the prevalence of AS over time was mainly driven by a sex imbalance in older women in this study, possibly due to the longer life expectancy and higher proportion of older women than men.

Our results demonstrate that the overall age‐standardized incidence of AS did not noticeably increase or decrease from 2006 to 2017. These findings are in contrast to the results of a Scottish hospital‐based study from 1997 to 2005 in which the age‐ and sex‐standardized incidence of AS increased from 246 cases in 1997 to 365 cases per million in 2005. 23 The incidence of AS in a nationwide study of the Swedish population decreased from 15.0 persons per 100 000 between 1998 and 1991 to 11.4 persons per 100 000 between 2007 and 2009 in men and from 9.8 persons per 100 000 between 1989 and 1991 to 17.1 persons per 100 000 persons between 2007 and 2009 in women. 2 However, the overall age‐standardized prevalence of AS increased from 2006 to 2017 in our study. This finding is similar to the prevalence of AS from a population‐based Norwegian study that showed a prevalence of 0.2% in individuals 50–59 years old, 1.3% in those 60–69 years old, 3.9% in those 70–79 years old, and 9.8% in those 80–89 years old. 27 Therefore, the prevalence of AS might continue to increase in Korea. Korea became an aging society in 2001, became an aged society in 2017, and is expected to become a super‐aged society, in which the proportion of the population over the age of 65 years will be greater than 20% of the whole population, by 2026. The age‐standardized death rate of AS decreased from 2006 to 2017 in our study. Therefore, we think that increased prevalence rate of AS in this study result from steady incidence rate and decreased death rate of AS during the period of our study.

The four leading causes of death in patients with AS in our study were disease of the circulatory system; malignant neoplasm; disease of the respiratory system; and symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified. Diseases of the circulatory system and malignant neoplasm were the main causes of death in both Korean women and men with AS. However, the third leading cause of death in Korean men was disease of the respiratory system, while that in women was symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified. We are not able to explain this difference between men and women. However, the main cause of death in individuals with AS was disease of the circulatory system. This result is in close agreement with those of a 3815 patient Japanese multicentre AS registry study. 28 The three most common co‐morbidities in newly diagnosed AS in this study were hypertension, heart failure, and dyslipidaemia. From the perspective of public health, it is important for elderly AS patients to prevent progression to complications such as heart failure. Education about using anti‐hypertensive medication, maintaining a low salt diet, and appropriate physical exercise is required for each AS patients. We suggest, based on our clinical experience, that such interventions will help maintain or improve the quality of life in elderly AS patients regardless of severity and with or without surgery or procedures for treatment. The functional longevity of Korean AS patients can be increased through these interventions.

Several limitations of the current study need to be acknowledged. First, the National Health Insurance Benefit records might have missed AS patients who did not use medical services or who paid for their own medical expenses. For this reason, the incidence, prevalence, death rate, SR, and death risk of AS in this study might be under‐ or overestimated. Second, the inherent limitations of the KNHIS database did not allow us to assess clinical results such as echocardiography, electrocardiography, or cardiac magnetic resonance imaging. Thus, severity of AS could not be assessed. Third, we did not evaluate replacement of artificial valves or valvuloplasty related to severity of AS and anti‐hypertensive medication or lipid‐lowering agents use because of data limitations.

Conclusions

The death risk associated with AS increased with older age, male sex, lower socioeconomic position, and in those with myocardial infarction, with heart failure, with stroke, with CKD, or with malignant neoplasm. The proportion of AS patients ≥60 years old was 80%. The 10 year SR with AS was about 50%. The age‐standardized incidence, prevalence, and death rate of AS were about 1 person, 3 persons, and 0.2 persons per 100 000 in 2017, respectively. The major cause of death for AS patients was disease of the circulatory system. These patterns indicated that AS can be considered a degenerative disease with effects that increase with age. Our findings should be considered in future research designs and policies addressing healthcare for AS patients.

Conflict of interest

None declared.

Supporting information

Table S1. Age‐standardized incidence a and 95% confidence interval (CI) of aortic stenosis overall and by sex (per 100,000).

Table S2. Age‐standardized prevalence a and 95% confidence interval (CI) of aortic stenosis overall and by sex (per 100,000).

Table S3. Age‐standardized death rate a and 95% confidence interval (CI) of aortic stenosis overall and by sex (per 100,000).

Table S4. Survival rate (SR, %) and 95% confidence interval (CI) of aortic stenosis overall and by sex and age group.

Click here for additional data file. (392.5KB, doc)

Acknowledgements

We used data from the National Health Insurance Service (research management number NHIS‐2019‐1‐147), but the study results are not related to the National Health Insurance Service.

Jang, S. Y. , Park, S.‐J. , Kim, E. K. , and Park, S. W. (2022) Temporal trends in incidence, prevalence, and death of aortic stenosis in Korea: a nationwide population‐based study. ESC Heart Failure, 9: 2851–2861. 10.1002/ehf2.13957.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Table S1. Age‐standardized incidence a and 95% confidence interval (CI) of aortic stenosis overall and by sex (per 100,000).

Table S2. Age‐standardized prevalence a and 95% confidence interval (CI) of aortic stenosis overall and by sex (per 100,000).

Table S3. Age‐standardized death rate a and 95% confidence interval (CI) of aortic stenosis overall and by sex (per 100,000).

Table S4. Survival rate (SR, %) and 95% confidence interval (CI) of aortic stenosis overall and by sex and age group.

Click here for additional data file. (392.5KB, doc)

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