What is the most appropriate next step for an asymptomatic male patient with severe aortic stenosis (AS) and normal ejection fraction (EF), who jogs daily without symptoms?

Management of Asymptomatic Severe Aortic Stenosis with Normal Ejection Fraction

Exercise stress testing is the most appropriate next step for this asymptomatic male patient with severe aortic stenosis, late-peaking carotid pulse, normal ejection fraction, and regular physical activity. 1, 2

Rationale for Exercise Testing

Exercise testing is crucial in this scenario for several important reasons:

• It unmasks symptoms that may not be apparent at rest in patients who consider themselves asymptomatic
• Up to 29% of seemingly asymptomatic patients develop symptoms during exercise testing 2
• The European Society of Cardiology (ESC) guidelines clearly indicate that exercise testing is essential to determine true symptomatic status in patients with severe aortic stenosis 1
• For active patients like this one who jogs 3 km daily, exercise capacity assessment is particularly important to reveal potential limitations

Clinical Decision Pathway Based on Exercise Test Results

If Exercise Test Reveals Symptoms or Abnormal Response:

• Aortic valve replacement (AVR) is indicated (Class I recommendation) if:
  • Patient develops symptoms clearly related to aortic stenosis during exercise 1
  • Blood pressure falls below baseline during exercise 1
• These findings indicate a poor prognosis with only 19% symptom-free survival at 2 years 2

If Exercise Test is Normal:

• Assess for high-risk features that may warrant early intervention:
  • Very severe AS (peak velocity >5.5 m/s) 1
  • Rapid progression (increase in velocity ≥0.3 m/s per year) 1
  • Severe valve calcification 1, 2
  • Elevated BNP levels 1, 2
  • Excessive LV hypertrophy in absence of hypertension 1

Important Considerations

1. Paradoxical Low-Flow, Low-Gradient AS: Despite having a gradient >40 mmHg, it's important to verify the flow status, as low-flow severe AS (stroke volume index ≤35 mL/m²) with preserved EF has worse prognosis 3, 4

2. Recent Evidence: The AVATAR trial showed that early SAVR in asymptomatic patients with severe AS reduced the composite endpoint of death, MI, stroke, and heart failure hospitalizations compared to conservative treatment 5

3. Surveillance Protocol: If conservative management is chosen after normal exercise testing and absence of high-risk features:

   • Clinical evaluation every 6 months
   • Echocardiography every 6-12 months 2
   • Patient education about prompt symptom reporting

Common Pitfalls to Avoid

1. Underestimating Symptom Status: Many patients unconsciously reduce their activity level to avoid symptoms; thorough exercise testing is essential

2. Delaying Intervention: Waiting until symptoms naturally develop carries risk of sudden death and irreversible myocardial damage 2

3. Misinterpreting Flow-Gradient Patterns: Low-flow, low-gradient severe AS despite preserved EF is associated with worse outcomes and should not be underestimated 3

4. Neglecting Regular Monitoring: Close surveillance is critical if conservative management is chosen

Exercise testing is the critical first step that will guide all subsequent management decisions for this patient with asymptomatic severe aortic stenosis.