From the Guidelines
Aortic stenosis is not primarily a genetic condition, but rather is caused by age-related calcification of the aortic valve, congenital bicuspid valve abnormalities, or rheumatic heart disease. Management of aortic stenosis depends on the severity of the condition, with surgical valve replacement being the definitive treatment for severe symptomatic cases.
Causes of Aortic Stenosis
- Age-related calcification of the aortic valve
- Congenital bicuspid valve abnormalities
- Rheumatic heart disease In asymptomatic patients with mild to moderate stenosis, regular monitoring with echocardiography every 1-2 years is recommended, along with management of cardiovascular risk factors 1.
Management of Aortic Stenosis
- Medical therapy focuses on treating symptoms and includes cautious use of diuretics for congestion, avoiding vasodilators that can cause hypotension, and managing atrial fibrillation with rate control and anticoagulation if needed
- Balloon valvuloplasty provides temporary relief in select cases but isn't durable
- The main surgical options are surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR), with TAVR increasingly used for intermediate and high-risk surgical patients, as supported by recent guidelines 2 The choice between SAVR and TAVR should be made after multidisciplinary discussion involving cardiologists, surgeons, and anaesthesiologists, taking into account patient characteristics and type of surgery. Patients should be educated about reporting symptoms like chest pain, shortness of breath, or syncope promptly, as these indicate disease progression. Endocarditis prophylaxis is recommended for patients with prosthetic valves. The progressive narrowing of the valve opening increases left ventricular pressure, leading to hypertrophy and eventually heart failure if left untreated, which explains why timely intervention is crucial.
Key Considerations
- Hypertension is a risk factor for the development of aortic stenosis and asymptomatic aortic stenosis, and its treatment is beneficial in patients with hypertension and aortic stenosis 3
- Careful use of antihypertensive agents to achieve blood pressure control in patients with hypertension and aortic stenosis is recommended, with consideration of the potential benefits of RAS blockade on left ventricular fibrosis.
From the Research
Cause of Aortic Stenosis
- Aortic stenosis (AS) is a complex disease with multiple causes, including congenital and acquired factors 4, 5.
- Congenital AS is often associated with bicuspid aortic valve, which can lead to primary anatomic narrowing of the valve 4.
- Acquired AS in adults is often degenerative, involving progressive calcification of an anatomically normal, tricuspid aortic valve 4, 6.
- Genetic factors play a significant role in the development of AS, with certain genetic variants increasing the risk of AS 7, 8.
Genetic Component of Aortic Stenosis
- Studies have shown that there is a familial component to AS, with siblings of patients with AS having an increased risk of developing the disease 7.
- A genome-wide association study (GWAS) found 17 AS risk loci, including 5 novel and independently replicated associations 8.
- The study also found that 11 of the associated loci were specific to AS and not associated with coronary artery disease (CAD) 8.
Management of Aortic Stenosis
- Aortic valve replacement is the standard treatment for patients with severe or symptomatic AS 4.
- Transcatheter or surgical intervention may be required for patients with congenital AS throughout their lives 5.
- The management of AS patients should include the evaluation of generalized atherosclerotic manifestations and individual frailty beyond generic risk scores 6.
- Novel therapeutics for congenital AS are being developed, based on the integration of molecular and genetic advances 5.