What is the management approach for an elderly patient with severe aortic stenosis (AS) and suspected coronary abnormalities?

Management of Severe Aortic Stenosis with Coronary Abnormalities in Elderly Patients

In elderly patients with severe aortic stenosis and suspected coronary abnormalities, coronary angiography must be performed before aortic valve replacement, and combined surgical aortic valve replacement with coronary artery bypass grafting is indicated when significant coronary disease is present. 1

Preoperative Coronary Assessment

Coronary angiography is mandatory before valve surgery in elderly patients with severe AS, particularly when any of the following are present 1:

• History of cardiovascular disease or suspected myocardial ischemia 1
• Men aged >40 years and post-menopausal women 1
• One or more cardiovascular risk factors 1
• Presence of angina pectoris - which has 78% sensitivity and 82% specificity for obstructive coronary artery disease in elderly AS patients 2

The ACC/AHA guidelines explicitly state that preoperative coronary angiography should be performed routinely as determined by age, symptoms, and coronary risk factors 1. This is critical because coronary artery disease and aortic stenosis share pathophysiological mechanisms and frequently coexist, with prevalence increasing substantially in elderly populations 3, 4.

Treatment Strategy Based on Surgical Risk

Low to Intermediate Surgical Risk

Combined surgical aortic valve replacement (SAVR) and coronary artery bypass grafting (CABG) is the Class I indication for patients with severe AS undergoing CABG 1. This approach:

• Provides superior long-term mortality benefit, especially with complex coronary disease 5
• Addresses both pathologies definitively in a single operation 1
• Is associated with higher periprocedural risk but better long-term outcomes 5

Even moderate AS warrants consideration for valve replacement during CABG (Class IIa recommendation), as progression may be rapid in elderly patients with calcified valves 1.

High or Prohibitive Surgical Risk

Transcatheter aortic valve replacement (TAVR) becomes the preferred intervention when 1:

• STS-PROM score >8% 1
• Significant frailty not captured by risk scores 1
• Anatomic factors increasing surgical risk (porcelain aorta, hostile chest) 1
• Significant comorbidities (lung disease, liver disease, malignancy) 1

For coronary revascularization in TAVR candidates 1:

• Percutaneous coronary intervention (PCI) before TAVR is appropriate for patients with intermediate or high surgical risk and less complex coronary disease 1
• The SYNTAX score guides complexity assessment and treatment selection 1
• Timing options include: PCI before TAVR, concomitant TAVR and PCI, or PCI after TAVR 5

Critical Clinical Considerations

Symptom Assessment

All three classic symptoms mandate urgent intervention 1:

• Angina pectoris - strongly predicts obstructive CAD (78% of elderly AS patients with angina have significant coronary disease) 2
• Syncope or near-syncope 6
• Congestive heart failure/dyspnea 1, 6

Once symptoms develop, prognosis deteriorates rapidly with sudden cardiac death risk of 8-34% 1. The ESC guidelines note that sudden death is rare in asymptomatic patients but increases dramatically after symptom onset 1.

Left Ventricular Function

AVR is indicated for severe AS with LV systolic dysfunction (ejection fraction <50%) regardless of symptoms 1. The ACC/AHA guidelines are even more stringent, recommending intervention when LVEF drops below 60% over serial echocardiography 1.

For low-flow, low-gradient AS with reduced LVEF 1:

• Dobutamine stress echocardiography is required to distinguish true-severe from pseudo-severe AS 1
• Patients with contractile reserve (>20% increase in stroke volume) should undergo AVR 1
• Those without contractile reserve have poor prognosis but may still benefit from AVR with individualized decision-making 1

Common Pitfalls to Avoid

Do not defer coronary angiography in elderly patients with severe AS - the guidelines are explicit that routine preoperative angiography should be performed 1. Waiting for diagnostic angiography delays appropriate management 2.

Do not assume absence of CAD based solely on lack of angina - while angina has high specificity (82%) for CAD, 17% of elderly AS patients without angina still have obstructive coronary disease 2.

Do not perform isolated AVR when significant CAD is present in surgical candidates - combined SAVR and CABG is the Class I recommendation and provides better long-term outcomes 1, 5.

Do not use medical therapy as definitive treatment for symptomatic severe AS - AVR is the only effective treatment for severe symptomatic calcific AS in adults 1. Medical management is appropriate only when life expectancy is <1 year or overall health status is dominated by comorbidities rather than AS 1.