What is the recommended frequency of monitoring for patients with moderate to severe aortic (aortic valve) stenosis?

From the Guidelines

Patients with moderate to severe aortic stenosis should undergo echocardiographic monitoring every 6-12 months for moderate stenosis and every 6 months for severe stenosis, as recommended by the 2020 ACC/AHA guideline for the management of patients with valvular heart disease 1. This monitoring schedule should be adjusted based on symptom development, with more frequent evaluations if symptoms like chest pain, shortness of breath, or syncope emerge.

Key Considerations

• Clinical evaluation should accompany each echocardiogram to assess for symptom development, which is a critical indicator for intervention timing.
• For asymptomatic patients with severe aortic stenosis, additional testing such as exercise stress testing may be warranted to unmask symptoms or abnormal blood pressure responses.
• Monitoring should include assessment of valve area, mean gradient, peak velocity, left ventricular function, and pulmonary artery pressure.
• More frequent monitoring (every 3-6 months) is recommended for patients with very severe aortic stenosis (peak velocity >5 m/s or mean gradient >60 mmHg) or declining left ventricular function, as stated in the 2020 ACC/AHA guideline 1.

Rationale

The 2020 ACC/AHA guideline 1 emphasizes the importance of regular echocardiographic monitoring in patients with moderate to severe aortic stenosis to assess disease progression and guide treatment decisions.

• The guideline recommends that patients with severe AS undergo echocardiography every 6 months, while those with moderate AS should undergo echocardiography every 6-12 months 1.
• The 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease also supports the use of echocardiography for the diagnosis and assessment of AS severity, as well as for re-evaluation of patients with known AS and changing symptoms or signs 1. This surveillance strategy allows for timely intervention before irreversible cardiac damage occurs, as the natural history of severe aortic stenosis involves a prolonged asymptomatic period followed by rapid clinical deterioration once symptoms develop.

Additional Recommendations

• The degree of aortic valve calcification is a strong predictor of clinical outcome, even when evaluated qualitatively by echocardiography, and quantitation of aortic valve calcium by CT imaging may be useful in certain cases 1.
• Dobutamine stress echocardiography may be useful in patients with severe AS and left ventricular dysfunction to distinguish between severe AS with afterload mismatch and primary myocardial dysfunction with moderate AS 1.

From the Research

Frequency of Monitoring for Moderate to Severe Aortic Stenosis

• The frequency of monitoring for patients with moderate to severe aortic stenosis is crucial for optimal management of the condition.
• According to 2, serial Doppler echocardiography is recommended every six to 12 months for severe aortic stenosis, and every one to two years for moderate disease.
• This frequent monitoring allows for early detection of disease progression and timely intervention, such as aortic valve replacement, which is recommended for most symptomatic patients with evidence of significant aortic stenosis on echocardiography 2.
• In addition to echocardiography, multimodality imaging can help evaluate left ventricular remodeling response and improve risk stratification in patients with moderate aortic stenosis 3.

Management of Moderate Aortic Stenosis

• The management of moderate aortic stenosis is complex and requires a comprehensive approach, including clinical surveillance, echocardiographic monitoring, and consideration of aortic valve replacement 3.
• Antihypertensive treatment with β-blockade may be beneficial in patients with asymptomatic mild to moderate aortic stenosis, as it has been associated with lower risk of all-cause mortality, cardiovascular death, and sudden cardiac death 4.
• A practical guideline for echocardiographic assessment of aortic stenosis has been provided by the British Society of Echocardiography, which includes a step-by-step guide for high-quality echocardiographic studies and addresses challenging clinical scenarios 5.