What is the initial management approach for patients with aortic stenosis?

Initial Management of Aortic Stenosis

The initial management of aortic stenosis centers on comprehensive assessment of symptom status and disease severity through echocardiography, followed by multidisciplinary Heart Valve Team evaluation to determine the need for valve replacement versus watchful waiting. 1, 2

Immediate Assessment Framework

Symptom and Severity Evaluation

• Evaluate for the classic triad: angina, dyspnea, and syncope, as these symptoms dramatically reduce survival to 2-3 years without intervention 2, 3
• Confirm severe aortic stenosis by echocardiographic criteria: aortic valve area <1.0 cm², mean pressure gradient >40 mmHg, and peak velocity >4 m/s 2
• Echocardiography is sufficient for guiding management in 65-70% of patients, with multimodality imaging required in 25-30% when findings are uncertain 2
• Exercise testing can unmask symptoms in apparently asymptomatic patients, particularly important in elderly patients with reduced mobility where symptoms may be difficult to ascertain 2

Baseline Clinical Data Collection

• Obtain physical examination, standard blood tests, pulmonary function tests, electrocardiogram, complete blood count, basic metabolic profile, coagulation studies, troponin, brain natriuretic peptide, type and screen, and chest radiograph 1, 3
• Document any previous reactions to contrast agents or latex, and medication allergies 1
• Perform carotid ultrasound when indicated 1
• Obtain dental evaluation with treatment of any acute issues prior to valve intervention to prevent prosthetic valve endocarditis 1

Heart Valve Team Approach

Multidisciplinary Decision-Making

• Assemble a Heart Valve Team including cardiologists with valvular expertise, structural interventional cardiologists, imaging specialists, cardiovascular surgeons, cardiovascular anesthesiologists, and nursing professionals 1
• The team must: 1) review medical condition and valve severity; 2) determine which interventions are indicated, technically feasible, and reasonable; 3) discuss benefits and risks with patient and family 1
• Establish patient goals and expectations early, including discussions of life expectancy, anticipated improvement in symptoms or survival, and end-of-life constructs when appropriate 1

Cardiovascular Comorbidity Assessment

• Perform coronary angiography in all patients being considered for intervention, as coronary artery disease is present in 40-75% of patients with aortic stenosis 1
• The Heart Valve Team should decide whether to revascularize before valve replacement on a case-by-case basis using individual anatomic, clinical, and physiological characteristics 1
• Evaluate for left ventricular systolic or diastolic dysfunction, severe mitral regurgitation or stenosis, and severe pulmonary hypertension by echocardiography 1
• Review previous cardiac surgical procedures or transcatheter interventions as these may affect the planned intervention 1

Treatment Algorithm Based on Symptom Status

Symptomatic Severe Aortic Stenosis

• Valve replacement (surgical or transcatheter) is strongly recommended for all symptomatic patients with severe aortic stenosis 2
• Decision between surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR) depends on surgical risk assessment using the Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) score 2
• Low surgical risk (STS-PROM <4%): generally undergo SAVR, especially in younger patients 2
• Intermediate surgical risk (STS-PROM 4-8%): may undergo either SAVR or TAVR based on patient factors 2
• High surgical risk (STS-PROM >8%): generally undergo TAVR 2

Asymptomatic Severe Aortic Stenosis

• Watchful waiting is recommended for most asymptomatic patients 4
• Serial Doppler echocardiography every 6-12 months for severe disease, every 1-2 years for moderate disease, and every 3-5 years for mild disease 4
• Select asymptomatic patients may benefit from valve replacement before symptom onset, particularly those with declining ejection fraction or very severe stenosis 4, 5
• Educate patients about the importance of promptly reporting symptoms, as 52% will develop symptoms, undergo valve replacement, or die within 3 years of diagnosis 5

Hemodynamic Management Principles

Heart Rate and Rhythm Control

• Heart rate control is essential, as both bradycardia and tachycardia can lead to clinical decompensation 2, 3
• Maintain normal sinus rhythm when possible, as atrial contribution to preload is critical in patients with left ventricular hypertrophy 3

Preload and Afterload Management

• Restore and maintain adequate preload as the first priority in hemodynamic management 3
• Careful fluid management is needed to maintain adequate preload without volume overload 2
• For patients with high blood pressure and heart failure symptoms, nitrate agents may be reasonable, but hypotension should be avoided 3
• Blood pressure control should be achieved cautiously, with target systolic blood pressure between 100-120 mmHg in acute settings 2
• Beta-blockers are preferred agents for blood pressure control due to their ability to reduce the force of left ventricular ejection 2

Management of Hypotension

• For hypotensive patients, vasopressors should be used at the lowest effective dose 3
• Dobutamine can increase inotropy in patients with decompensated heart failure 3

Special Clinical Scenarios

Low-Flow, Low-Gradient Aortic Stenosis

• Confirm true stenosis severity using dobutamine stress echocardiography or multi-slice computed tomography 2
• Intervention is recommended if true severe aortic stenosis is confirmed and flow reserve is present 2

Concurrent Coronary Artery Disease

• For patients with severe aortic stenosis and coronary artery disease, SAVR plus coronary artery bypass grafting is appropriate for most patients 2
• Revascularization with percutaneous coronary intervention or coronary artery bypass graft in addition to TAVR did not increase the risk of death or disabling stroke at 2-year follow-up in the PARTNER 2A trial 1

Other Valve Disease

• For patients with severe aortic stenosis and other valve disease, a surgical approach is generally preferred unless high surgical risk 2

Critical Pitfalls to Avoid

• Do not delay valve replacement in symptomatic patients, as survival without intervention is only 2-3 years once symptoms develop 2
• Consider medical futility in patients with life expectancy <1 year or severe dementia before proceeding with intervention 1, 2
• Palliative balloon aortic valvuloplasty may be considered in select patients with limited life expectancy as a temporizing measure 1, 2
• Evaluate social support, particularly with respect to transportation and recovery, before proceeding with intervention 1
• Among patients with asymptomatic severe aortic stenosis, the omission of surgical treatment was the most important risk factor for late mortality 5