What is the treatment for asymptomatic aortic (valve) stenosis?

From the Guidelines

Asymptomatic aortic stenosis is typically managed with watchful waiting and regular monitoring, as there is no specific therapy for asymptomatic aortic stenosis 1.

Treatment Approach

• The primary goal is to monitor the progression of the disease and adjust treatment as needed.
• Medications such as beta blockers (e.g., metoprolol 25-100 mg twice daily) may be prescribed to control heart rate and reduce the force of the heart's contraction, potentially slowing the progression of the disease.
• Statins (e.g., atorvastatin 20-80 mg daily) may also be recommended to manage cholesterol levels and reduce the risk of cardiovascular events.
• Surgical options include aortic valve replacement (AVR) with a mechanical or bioprosthetic valve, or transcatheter aortic valve replacement (TAVR) for patients who are at high risk for surgical complications.
• The decision to proceed with surgery is typically made when symptoms develop, such as chest pain, shortness of breath, or fainting, or when there are signs of severe aortic stenosis on echocardiography 1.

Monitoring and Follow-up

• Regular follow-up with a cardiologist, typically every 6-12 months, is essential to monitor the progression of the disease and adjust treatment as needed.
• Hypertension is a risk factor for aortic stenosis and associated with increased rate of progression and reduced survival, and treatment of hypertension is a valid target 1.
• The European Society of Cardiology (ESC) guidelines indicate valve replacement for those patients with severe aortic stenosis who have symptoms, impaired left ventricular (LV) systolic function, or in whom other cardiac surgery is being performed 1.

Individualized Approach

• The decision to proceed with an intervention must also be individualized for each patient, taking into account their own needs and preferences 1.
• A shared decision-making approach must be undertaken for each individual patient, considering factors such as age, comorbidities, and lifestyle 1.

From the Research

Treatment Approaches

The treatment for asymptomatic aortic (valve) stenosis is a subject of ongoing debate, with various studies suggesting different approaches. Some of the key points to consider include:

• Watchful waiting with regular follow-up exams is a common strategy for asymptomatic patients with severe aortic stenosis, as recommended by current guidelines 2, 3.
• Early valve replacement may be beneficial for certain patients with asymptomatic severe aortic stenosis, particularly those with high-risk features or abnormal exercise test results 4, 5.
• Transcatheter aortic valve replacement (AVR) is a viable alternative to surgical AVR, especially for patients at high or very high risk of cardiac surgery 3, 6.

Patient Selection

The decision to operate on asymptomatic patients with severe aortic stenosis depends on various factors, including:

• The presence of reduced systolic left ventricular function without other explanation 5.
• Abnormal exercise test results or a high likelihood of rapid progression 5.
• Very severe aortic stenosis in the presence of low surgical risk 5.
• Patient age, comorbidities, and overall health status 3, 4.

Monitoring and Follow-up

Asymptomatic patients with severe aortic stenosis require frequent monitoring of their subjective symptoms combined with objective measurement of aortic valve gradient and ventricular function by transthoracic echocardiography 3, 4. This allows for early detection of any changes in disease severity or the development of symptoms, which can inform the decision to proceed with valve replacement.