What is the management approach for a patient with aortic sclerosis and a developing gradient?

From the Guidelines

The management approach for a patient with aortic sclerosis and a developing gradient should prioritize regular monitoring, addressing cardiovascular risk factors, and considering valve replacement evaluation if symptoms develop or the aortic valve gradient progresses to severe stenosis. The most recent and highest quality study, 1, provides guidance on the management of patients with valvular heart disease, including those with aortic sclerosis and a developing gradient. Key aspects of management include:

• Echocardiographic surveillance every 1-2 years to track progression of the valve disease, with more frequent monitoring if the gradient increases significantly
• Risk factor modification, including blood pressure control with medications such as ACE inhibitors, ARBs, or calcium channel blockers, and statin therapy to potentially slow valve calcification progression
• Lifestyle modifications, including smoking cessation, regular exercise, weight management, and a heart-healthy diet
• Consideration of antiplatelet therapy with low-dose aspirin for patients with concomitant coronary artery disease
• Referral for valve replacement evaluation if the patient develops symptoms, such as dyspnea, angina, or syncope, or if the aortic valve gradient progresses to severe stenosis, defined as a mean gradient >40 mmHg or a valve area <1.0 cm², as indicated in 1 and supported by earlier guidelines 1. It is essential to weigh the benefits and risks of valve replacement, considering the patient's clinical condition, comorbidities, and the extent of valve calcification, as emphasized in 1. Ultimately, the goal of management is to prevent the progression of aortic sclerosis to severe aortic stenosis, reduce morbidity and mortality, and improve quality of life, as highlighted in the most recent guidelines 1.

From the Research

Management Approach for Aortic Sclerosis with Developing Gradient

The management of a patient with aortic sclerosis and a developing gradient involves a comprehensive approach, considering the patient's overall cardiovascular risk and the potential progression of the disease.

• The presence of aortic sclerosis is associated with an increased risk of cardiovascular mortality and morbidity, as shown in a study published in 2.
• Aortic valve sclerosis is defined as calcification and thickening of a trileaflet aortic valve in the absence of obstruction of ventricular outflow, and its frequency increases with age, making it a major geriatric problem 3.
• The incidence of aortic sclerosis increases with age, male gender, smoking, hypertension, high lipoprotein (Lp) (a), high low-density lipoprotein (LDL), and diabetes mellitus 3.
• Aggressive management of modifiable risk factors, especially LDL cholesterol lowering, may slow the progression of the disease 3.

Diagnostic Evaluation

• Echocardiography is critical in determining the severity of aortic stenosis and the presence of a developing gradient 4, 5.
• A multimodality imaging approach, including low-dose dobutamine stress echocardiography and aortic valve calcium scoring by multidetector computed tomography, may be necessary to confirm the presence of severe aortic stenosis in patients with low-gradient aortic stenosis 4.
• The aortic valve area should be measured in all patients with suspected severe aortic stenosis and a mean gradient of less than 50 mm Hg or a peak gradient of less than 60 mm Hg 5.

Treatment Options

• Patients with low-gradient severe aortic stenosis and evidence of severe aortic stenosis may benefit from aortic valve replacement (AVR) 4.
• Transcatheter AVR using a transfemoral approach may be superior to surgical AVR in patients with low-flow, low-gradient aortic stenosis 4.
• The outcome of patients with low-gradient "severe" aortic stenosis and preserved ejection fraction is similar to that of patients with moderate stenosis, as shown in a study published in 6.