What is the most appropriate management for an asymptomatic patient in their 70s with severe aortic stenosis, normal ejection fraction (EF), and normal left ventricle (LV)?

Management of Asymptomatic Severe Aortic Stenosis in a 70-Year-Old

For this asymptomatic patient in their 70s with severe aortic stenosis, normal ejection fraction, and normal left ventricle, the most appropriate management is close clinical surveillance with serial echocardiography (Option C: Follow up with ECO), unless specific high-risk features are identified that would warrant earlier intervention. 1

Rationale for Conservative Management

The current ACC/AHA and ESC guidelines do not mandate immediate intervention for asymptomatic severe aortic stenosis when left ventricular function is preserved, as these patients maintain a relatively benign prognosis with 1-year survival of 67% without intervention. 1 This contrasts sharply with symptomatic patients who face 25% mortality at 1 year and 50% at 2 years. 1

Medical management is rated as "Appropriate" (median score 7) for asymptomatic patients with severe AS, LVEF ≥50%, and no high-risk features, while intervention is rated as "May Be Appropriate" (median score 4). 2

Critical Assessment Required Before Deciding

Before committing to surveillance alone, you must actively exclude the following conditions that would change management to immediate intervention:

Class I Indications for Immediate AVR (Must Intervene):

• Reduced ejection fraction <50% - This is a Class I indication regardless of symptoms, and intervention is rated "Appropriate" (score 8-9) across all surgical risk categories. 2, 1

• Abnormal exercise stress test - If the patient develops symptoms on exercise or demonstrates fall in blood pressure below baseline, this effectively reclassifies them as symptomatic and warrants immediate intervention (rated "Appropriate" with score 8). 2, 1

• Any true symptoms - Dyspnea, angina, syncope, or presyncope by history converts this to a Class I indication. 2, 1

High-Risk Features That May Warrant Earlier Intervention:

Even in truly asymptomatic patients with preserved EF, intervention should be considered "Appropriate" (score 7-8) if one or more of these predictors of rapid progression are present: 2, 1

• Very severe AS with peak velocity >5.0-5.5 m/s
• Severe valve calcification with rapid progression (ΔVmax >0.3 m/s per year)
• Markedly elevated BNP levels (confirmed on repeated measurements)
• Excessive LV hypertrophy in the absence of hypertension

Recommended Surveillance Protocol

For truly asymptomatic severe AS with normal LV function and no high-risk features, implement the following monitoring schedule: 1

• Clinical follow-up every 6 months
• Transthoracic echocardiography every 12 months to assess valve area, gradients, and LV function
• More frequent monitoring (every 6 months) when LVEF approaches 60-65% or LV end-systolic diameter reaches 40-45 mm 1

Perform exercise stress testing if symptom status is unclear, particularly in elderly patients where symptoms may be masked by reduced activity levels or comorbidities, to objectively confirm asymptomatic status and identify those subconsciously limiting activities. 1

When Intervention Becomes Necessary

Choice Between TAVR vs SAVR:

If intervention becomes indicated during follow-up, for a patient in their 70s (age 75-80), both TAVR and SAVR are considered equivalent options. 1

• Mechanical valve replacement (Option A) is inappropriate - Bioprosthetic valves are recommended for patients over 65 years per ACC/AHA guidelines. 1

• For patients over 80, TAVR is preferred; for those 65-75, SAVR is generally preferred. 1

Recent Evidence on Early Intervention

Important caveat: The 2025 EARLY TAVR trial demonstrated that early TAVR was superior to clinical surveillance in reducing death, stroke, or unplanned cardiovascular hospitalization (26.8% vs 45.3%, HR 0.50, P<0.001) in asymptomatic severe AS patients. 3 However, this represents emerging evidence that has not yet been incorporated into formal guideline recommendations, and 87% of the surveillance group eventually underwent valve replacement during follow-up. 3 Current guidelines still support surveillance as the standard approach for truly asymptomatic patients without high-risk features. 2, 1

Critical Pitfalls to Avoid

• Do not assume the patient is truly asymptomatic without exercise testing - Elderly patients often unconsciously limit activities, masking symptoms. 1

• Do not wait for LVEF to drop below 50% - Emerging data suggest LVEF <55% may already represent a point of irreversible myocardial damage with worse outcomes even after intervention. 4

• Do not ignore rapid progression markers - Elevated BNP, severe calcification, and rapid velocity progression should prompt consideration of earlier intervention even in asymptomatic patients at low surgical risk. 2, 1