From the Guidelines
Clinically significant aortic stenosis requires prompt referral to a cardiologist or cardiac surgeon for valve replacement, either through surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR), as it is the only effective treatment for severe symptomatic aortic stenosis. The diagnosis of aortic stenosis is typically made when the valve area is less than 1.0 cm², mean pressure gradient exceeds 40 mmHg, or peak jet velocity is greater than 4 m/s on echocardiography, as noted in studies such as 1. Symptoms of aortic stenosis include chest pain, shortness of breath, fatigue, and syncope.
Key Considerations
- The condition progressively worsens over time as calcium deposits accumulate on the valve leaflets, causing increased left ventricular pressure and eventual heart failure if left untreated, highlighting the importance of regular monitoring with echocardiography, as recommended by 1.
- Medical therapy alone is insufficient for severe aortic stenosis but may include cautious use of diuretics for symptom management, avoidance of vasodilators, and management of comorbidities.
- Regular monitoring with echocardiography is essential, with follow-up every 6-12 months for severe asymptomatic stenosis and annually for moderate stenosis, as suggested by 1.
- The management of asymptomatic patients remains controversial and is mainly based on individual risk stratification, with studies such as 1 and 1 providing recommendations for utilization of multimodality imaging to optimize risk stratification and therapeutic decision-making processes in aortic stenosis.
Treatment and Management
- Valve replacement is the definitive treatment for severe symptomatic aortic stenosis, with both SAVR and TAVR being effective options, as noted in 1.
- The treatment of hypertension is a valid target in patients with aortic stenosis, with pragmatic goals being a systolic blood pressure of 130–139 mmHg and a diastolic blood pressure of 70–90 mmHg, as suggested by 1.
- Ongoing studies, such as the TAVR UNLOAD study mentioned in 1, are likely to clarify whether treatment of moderate AS in patients with reduced LVEF reduces all-cause deaths and hospitalizations related to heart failure.
From the Research
Definition and Symptoms of Clinically Significant Aortic Stenosis
- Aortic stenosis refers to significant narrowing of the aortic valve, which can be caused by calcific disease, congenital causes, or rheumatic valvular disease 2.
- Symptoms of advanced disease include angina, dyspnea, and syncope, and patients with these symptoms have a much higher mortality rate than asymptomatic patients 2, 3.
Diagnosis and Evaluation
- Initial evaluation should include an electrocardiogram, complete blood count, basic metabolic profile, coagulation studies, troponin, brain natriuretic peptide, type and screen, and a chest radiograph 2.
- Transthoracic echocardiogram is the test of choice, but point-of-care ultrasound has been found to have good accuracy when a formal echocardiogram is not feasible 2.
- Serial Doppler echocardiography is recommended every six to 12 months for severe aortic stenosis, every one to two years for moderate disease, and every three to five years for mild disease 3.
Management and Treatment
- Initial management should begin with restoring preload and ensuring a normal heart rate, as both bradycardia and tachycardia can lead to clinical decompensation 2.
- For patients with high blood pressure and heart failure symptoms, nitrate agents may be reasonable, but hypotension should be avoided 2.
- Aortic valve replacement is recommended for most symptomatic patients with evidence of significant aortic stenosis on echocardiography 3.
- Early surgery for asymptomatic aortic stenosis may be associated with significant reduction in all-cause and cardiovascular mortality 4.
- Antihypertensive treatment, including the use of β-blockers and renin-angiotensin system (RAS) inhibition, may be safe and beneficial in patients with severe aortic stenosis 5, 6.