Electronic physician notifications significantly increased the rate of specialist referrals for patients with suspected severe aortic stenosis (AS) through transthoracic echocardiogram (TTE) in the DETECT AS trial. Results and insights from the DETECT AS trial were presented as a rapid fire late-breaking abstract at the American Society of Echocardiography (ASE) 2025 Scientific Sessions.

The study authors emphasized that clearer communication in TTE reports can significantly enhance the quality of clinical care for patients with severe AS.

"These electronic provider notifications are a simple, scalable tool that can really bolster awareness and improve rates of referral, to really move patients along in their care journey for severe aortic stenosis," said study investigator Varsha Tanguturi, MD, a cardiologist at Massachusetts General Heart Center in Boston, when presenting the findings at the ASE 2025 meeting. 

Untreated patients with symptomatic severe AS face a high degree of morbidity and mortality. Timely treatment is key for these patients, and will become even more important as the ACC/AHA seeks to track and report on the proportion of patients with symptomatic, severe AS whoF receive aortic valve replacement (AVR) within 90 of diagnosis. AVR is curative for these patients but remains underutilized.  

The DETECT AS study was a pragmatic, cluster, randomized, multi-center trial that evaluated the impact of provider notifications on referral rates within 1 year of a patient undergoing a diagnostic TTE to identify their severe AS. In the study, 285 providers caring for patients with potential severe AS were randomly assigned to receive medical record notifications of the detection of severe AS or usual care. The providers receiving email and electronic notifications were sent clinical guideline recommendations. Usual care consisted only of standard echocardiography reports in the patient’s medical record. Within the study, potential severe AS was defined as aortic valve area of no more than 1 cm².

The DETECT AS study looked at rates for primary care physicians and other non-cardiac specialists referring patients to cardiologists or procedural valve specialists as well as from cardiologists to procedural valve specialists. Patients were followed through 1 year from enrollment. 

Among the 144 providers randomized to receive notifications and 141 assigned to usual care, 496 and 443 patients, respectively, were cared for in each group. Most providers were cardiologists (48%) followed by primary care physicians (33%) and other specialists (15%); only 4% of providers were procedural valve specialists. Excluding the patients primarily cared for by the procedural specialists, total patients was 778 patients between the 2 study arms.

Overall, the electronic provider notifications improved the rates of patients who went on to undergo AVR as well as survival outcomes. At 1 year of follow-up, 60% of symptomatic patients with severe AS underwent AVR in the notification arm compared with 47% in the usual care arm (hazard ratio [HR] = 1.40), across all provider specialties. This led to a restricted mean survival time of 335 days in the notification arm and 312 days in the usual care arm. The difference between the two arms was 23 days. 

Referral to cardiology from non-cardiac specialists and primary care physicians was more common with the physicians who received the notifications compared with those who did not (67.9% vs 43.2%). Referral rates from cardiology to procedural valve specialists were 53.6% with notifications versus 45.8% without.

Among all physicians receiving notifications, referral rates were highest among the patients cared for by non-cardiac physicians versus by cardiologists (P = .03). "I think this really highlights the fact that telling people about their patients' severe AS is especially welcomed by our colleagues who may be less familiar with the complexity of an AS diagnosis and may really impact their decision-making," Dr. Tanguturi said. When asked why this was the case, she commented that "on a finding that you don't know anything about ... the threshold to act is far lower."

In the notification arm, referral rates were higher for patients being cared for by non-cardiac providers vs cardiologists (HR = 1.52). Comparatively, differences were non-significant in the usual care arm between non-cardiac and cardiac providers (P = .93).

When adjusting for variables, notifications were associated with a higher rate of referral (HR = 1.43). Variables associated with a lower chance of specialist referral included age over 80 years (HR = 0.67; 95%), mean aortic valve gradient under 40 mmHg (HR = 0.28), asymptomatic (HR = 0.4), and outpatient TTE (HR = 0.78).

Across all subgroups analyzed, notifications improved the rates of referrals to specialists for patients with possible severe AS.

Among a subgroup of symptomatic patients, electronic notifications were associated with higher referral rates (66.8% vs 56.3% in control arm) by both unadjusted and adjusted analysis (HR = 1.27). They also had a two-fold higher chance of referral in the notification arm when cared for by non-cardiac providers (HR = 2.04) in unadjusted analyses.

A subgroup of patients with high mean aortic valve gradient had higher rates of referral with electronic notification than with usual care (81.4% vs 63.8%). Specifically, among patients cared for by primary care physicians or other non-cardiac specialists, the likelihood of referral was much higher (HR = 2.39) compared with by cardiologist care (HR = 1.4).

In patients with low mean aortic valve gradient, comparatively, referral rates were also higher with electronic notification than with usual care (45.8% vs 33.3%) across all provider specialties. Differences in referral rates were insignificant for patients with low gradient severe AS who were cared for by primary care physicians or other non-cardiac specialists (HR = 1.54).

Notably, patients who underwent TTE in an inpatient setting were considerably more likely to receive a referral for AVR with notifications than without (60% vs 39.8%). Differences in the outpatient setting were considered not statistically significant. 

Dr. Tanguturi noted that there were marked increases for the historically under-treated subgroup of female patients, elderly patients, and inpatients. "It's very possible that these notifications help with communication across these discreet episodes of care," she said.