What are the treatment options for an elderly patient with aortic valve thickening (aortic stenosis) and a history of cardiovascular disease?

Treatment of Aortic Valve Thickening (Aortic Stenosis) in Elderly Patients with Cardiovascular Disease

For elderly patients with symptomatic severe aortic stenosis and cardiovascular disease, aortic valve replacement (either TAVR or SAVR) is the definitive treatment that improves survival and relieves symptoms, with TAVR preferred in patients with frailty, significant comorbidities (lung/liver disease, malignancy), or anatomical factors that increase surgical risk. 1

Symptomatic Severe Aortic Stenosis

Intervention is appropriate for all symptomatic patients with severe AS, regardless of surgical risk, as this improves both mortality and quality of life. 1 The key exception is when life expectancy is less than one year due to comorbidities that dominate the clinical picture more than the AS itself—in these cases, medical management becomes appropriate. 1

Choosing Between TAVR and SAVR

The decision algorithm prioritizes:

• TAVR is appropriate for patients with:

  • Frailty not captured by standard risk scores 1
  • Porcelain aorta or hostile chest 1
  • Significant comorbidities including chronic lung disease, liver disease, malignancy, or dementia 1
  • Advanced age with multiple comorbidities 1

• SAVR is appropriate for patients with:

  • Low to moderate surgical risk 1
  • Normal coronary arteries and preserved LV function (better outcomes) 1
  • Concomitant coronary artery disease requiring CABG (improved long-term mortality with combined procedure) 2

Concomitant Coronary Artery Disease

When significant CAD (>50% stenosis) coexists with severe AS:

• If SAVR is chosen: Concomitant CABG is appropriate and improves long-term outcomes, particularly with complex CAD, despite higher periprocedural risk. 1, 2
• If TAVR is chosen: Percutaneous coronary intervention should be performed for significant lesions, though optimal timing (before, during, or after TAVR) lacks definitive evidence. 1, 3

Asymptomatic Severe Aortic Stenosis

Intervention is appropriate in asymptomatic patients when: 1

• Ejection fraction <50%
• Positive exercise stress test (effectively makes them symptomatic)
• Very severe AS (aortic velocity >4.5-5 m/s or mean gradient >50 mmHg) 1, 4
• Rapid disease progression or significant valve calcification 1

Watchful waiting with close monitoring is appropriate for truly asymptomatic patients without these high-risk features. 5

Medical Management (When Intervention Not Appropriate)

Medical therapy does not prolong life in severe AS but can provide symptomatic relief in select scenarios: 1

• Heart failure symptoms: Cautious use of diuretics, digitalis (only if reduced EF or atrial fibrillation), and ACE inhibitors—but avoid excessive preload reduction as it can precipitate hypotension and reduced cardiac output in the small hypertrophied ventricle. 1

• Angina: Cautious use of nitrates and beta-blockers. 1

• Atrial fibrillation: Immediate cardioversion or aggressive rate control is essential, as loss of atrial kick significantly compromises cardiac output. 1

• Acute pulmonary edema: Nitroprusside infusion in ICU with invasive hemodynamic monitoring. 1

Medical management is appropriate when: 1

• Life expectancy <1 year from non-cardiac causes
• Moderate to severe dementia
• Advanced cancer or permanent neurological deficits from stroke 1

In these futility scenarios, palliative balloon valvuloplasty may be appropriate for temporary symptom relief. 1

Post-TAVR Management

After TAVR, standard antithrombotic therapy consists of: 6

• Clopidogrel 75 mg daily for 3-6 months plus aspirin 75-100 mg daily lifelong (if no anticoagulation indication) 6
• Anticoagulation per atrial fibrillation guidelines if chronic AF or other indication exists 6
• Echocardiography before discharge, at 30 days, then annually to monitor valve function 6
• Periodic ECG monitoring for new-onset atrial fibrillation (occurs in <1-8.6% post-TAVR) 6

Critical Pitfalls to Avoid

• Do not delay intervention in symptomatic severe AS—survival drops rapidly once symptoms appear, with 50% mortality at 2 years without valve replacement. 4, 5

• Do not use excessive diuresis in AS patients with heart failure, as the hypertrophied ventricle is preload-dependent and hypotension can result. 1

• Do not assume asymptomatic status in elderly patients—perform exercise testing if symptom status is unclear due to deconditioning or comorbidities. 1

• Do not overlook concomitant CAD—it significantly impacts treatment selection and outcomes, particularly with surgical approaches. 1, 2

• Advanced age alone is not a contraindication to AVR—valve replacement is technically possible at any age, and outcomes depend more on comorbidities than chronological age. 1