What is the best course of treatment for an older adult patient with aortic stenosis (AS) experiencing chest pain?

Management of Chest Pain in Older Adults with Aortic Stenosis

An older adult patient with aortic stenosis presenting with chest pain requires immediate assessment of AS severity and symptom status, followed by prompt aortic valve replacement (surgical or transcatheter) if severe symptomatic AS is confirmed, as this is a Class I indication that directly impacts mortality. 1, 2

Initial Diagnostic Approach

Confirm AS severity immediately using echocardiography with the following criteria defining severe AS: 2, 3

• Aortic valve area ≤1.0 cm²
• Peak velocity ≥4 m/s
• Mean gradient ≥40 mmHg

Determine if chest pain is truly angina related to AS by assessing: 2

• Exertional nature of chest pain
• Associated symptoms: dyspnea, syncope, or dizziness
• Exercise capacity limitations below predicted metabolic equivalents

Critical caveat: Not all chest pain in AS patients is valve-related. One case report demonstrated successful management of a patient with critical AS and angina through PCI alone when concomitant coronary disease was the culprit. 4 However, this represents the exception rather than the rule and requires careful exclusion of other pathology.

Risk Stratification for Treatment Planning

Calculate surgical risk using the STS-PROM score: 2

• Low risk: STS-PROM <3%
• Intermediate risk: STS-PROM 4-8%
• High risk: STS-PROM >8%
• Prohibitive risk: ≥50% mortality or irreversible morbidity at 30 days

Assess additional risk factors not captured by STS score: 1, 2

• Frailty status
• Porcelain aorta or hostile chest
• Prior radiation therapy
• Severe hepatic or pulmonary disease

Treatment Algorithm for Symptomatic Severe AS

For Symptomatic Patients (Including Chest Pain/Angina):

Proceed immediately with valve replacement - this is non-negotiable as symptomatic severe AS carries 25% mortality at 1 year and 50% at 2 years without intervention. 5, 3

Choice of intervention based on age and surgical risk: 3

• Age ≤65 years: Surgical AVR is recommended
• Age 66-79 years: Either surgical AVR or TAVR is appropriate
• Age ≥80 years OR STS score ≥8%: TAVR is preferred

For prohibitive surgical risk patients: TAVR is the only option if predicted post-TAVR survival >12 months. 1, 2

Special Consideration for Low-Flow, Low-Gradient AS:

If the patient has reduced LVEF with chest pain but gradients appear lower than expected: 2

• Perform dobutamine stress echocardiography
• If mean gradient reaches >40 mmHg with dobutamine, proceed with valve replacement
• There is no lower LVEF limit for intervention in symptomatic patients with confirmed severe AS

Medical Management While Awaiting Intervention

Critical principles to prevent hemodynamic destabilization: 1, 2

• Maintain adequate preload - avoid excessive diuresis
• Control heart rate to preserve diastolic filling time
• Avoid vasodilators and positive inotropes - these can cause catastrophic hypotension
• Control blood pressure appropriately but cautiously
• Do NOT use statins to prevent AS progression (ineffective for this purpose)

Common pitfall: Aggressive diuresis or vasodilator therapy in AS patients with chest pain can precipitate cardiovascular collapse, as these patients are preload-dependent. 1

Alternative Interventions for Non-Surgical Candidates

Balloon aortic valvuloplasty is reasonable only as: 1

• Palliative therapy when AVR cannot be performed due to serious comorbidities (Class IIb)
• Bridge to surgical AVR (Class IIb)
• Not a definitive treatment due to high restenosis rates

Multidisciplinary Heart Team Evaluation

All complex decisions require Heart Team assessment including: 2

• Cardiac surgery
• Interventional cardiology
• Cardiac imaging specialists
• Anesthesiology
• Geriatrics expertise

This team-based approach is foundational for TAVR and ensures optimal patient selection and procedural planning. 1

Expected Outcomes

TAVR outcomes in appropriate patients: 2

• Sustained mortality benefit at 2 years versus medical therapy
• Improved functional status
• Reduced rehospitalization rates
• Shorter hospitalization and faster recovery versus SAVR

Surgical AVR outcomes: 1

• 3% mortality
• 2% stroke risk
• 11% prolonged ventilation
• Higher complications when combined with CABG

TAVR-specific complications to counsel patients about: 1, 2

• 3-5% mortality
• 6-7% stroke risk
• 17% access complications
• Permanent pacemaker requirement (2-43% depending on valve type)
• Paravalvular aortic regurgitation
• Acute kidney injury

The bottom line: Chest pain in an older adult with severe AS is a red flag symptom demanding urgent valve replacement evaluation, as medical therapy alone is associated with dismal prognosis (50% mortality at 2 years), while valve replacement restores life expectancy to age-matched controls. 5, 3