From the Guidelines
Mild-to-moderate aortic stenosis (AS) primarily requires regular monitoring and management of symptoms rather than immediate intervention, with a focus on treating coexisting conditions like hypertension to improve quality of life and reduce morbidity and mortality. Patients should undergo clinical evaluation every 1-2 years for mild AS and annually for moderate AS, with echocardiography recommended every 3-5 years for mild AS and every 1-2 years for moderate AS 1. No specific medications are indicated to slow progression of AS itself, but management focuses on treating coexisting conditions like hypertension, preferably with ACE inhibitors, ARBs, or diuretics, as these have been shown to be beneficial in patients with AS and hypertension 1.
Some key points to consider in the management of mild-to-moderate AS include:
- Regular monitoring of symptoms and echocardiography to assess disease progression
- Treatment of coexisting conditions like hypertension to reduce cardiovascular morbidity and mortality
- Avoidance of strenuous exertion, particularly for moderate AS
- Education of patients about symptoms that warrant prompt medical attention, including chest pain, shortness of breath, dizziness, or syncope
- Consideration of valve replacement in patients with severe AS or those who develop symptoms, as this is the definitive therapy for severe AS and can improve long-term survival rates and quality of life 1.
It is also important to note that AS is typically progressive, and approximately 10% of patients with moderate AS progress to severe disease annually, at which point intervention may become necessary 1. Therefore, regular follow-up is essential to monitor disease progression and adjust management accordingly.
In terms of specific management strategies, the use of ACE inhibitors or ARBs is recommended for patients with AS and hypertension, as these agents have been shown to be beneficial in reducing blood pressure and improving outcomes in patients with cardiovascular disease 1. Beta-blockers should be used cautiously in patients with AS, as they may reduce cardiac output, but may be beneficial in patients with reduced ejection fraction, prior MI, arrhythmias, or angina pectoris 1.
Overall, the management of mild-to-moderate AS should focus on regular monitoring, treatment of coexisting conditions, and education of patients about symptoms that warrant prompt medical attention, with the goal of improving quality of life and reducing morbidity and mortality.
From the Research
Management Approach for Mild-to-Moderate Aortic Stenosis (AS)
- For asymptomatic patients with mild-to-moderate AS, watchful waiting is recommended 2.
- Serial Doppler echocardiography is recommended for asymptomatic patients, with the frequency of monitoring depending on the severity of the disease: every 3-5 years for mild disease, every 1-2 years for moderate disease, and every 6-12 months for severe disease 2.
- Medical management of concurrent conditions such as hypertension, atrial fibrillation, and coronary artery disease is important for optimal outcomes 2.
- For patients with moderate AS, there is no clear recommendation on when to intervene, but recent literature suggests that these patients may experience symptoms and have a poorer prognosis than previously reported 3.
- Early aortic valve intervention may be beneficial for patients with moderate AS and left ventricular dysfunction, but more research is needed to determine the best approach 3.
- Renin-angiotensin system (RAS) blockade therapy may be associated with slower progression of aortic valve calcification, left ventricular mass, and survival benefit in patients with AS before and after aortic valve replacement (AVR) 4.
- The role of RAS inhibition in patients with AS is still being studied, and adequately powered randomized trials are needed to evaluate its effectiveness 4.