What are the primary considerations and treatment options for an older adult with aortic stenosis and comorbidities like hypertension and hyperlipidemia?

Pitfalls in Aortic Stenosis Management

Critical Medication Errors

The most dangerous pitfall is avoiding antihypertensive therapy in patients with aortic stenosis and hypertension—this outdated fear of hypotension increases cardiovascular morbidity and mortality. 1

Hypertension Management Misconceptions

• Hypertension must be treated in patients with asymptomatic aortic stenosis (Class I recommendation), starting at low doses and gradually titrating upward as needed 1
• The combination of hypertension and aortic stenosis creates "2 resistors in series," which significantly increases complications and mortality 1
• There is no evidence that antihypertensive medications produce excessive hypotension in aortic stenosis patients—nitroprusside infusion actually improves stroke volume and reduces LV end-diastolic pressure in these patients 1

Beta Blocker Misuse

• Beta blockers should be avoided in patients with concurrent aortic regurgitation unless there are compelling indications (heart failure with reduced ejection fraction, post-MI, arrhythmias, or angina) 1, 2, 3
• Beta blockers slow heart rate and increase diastolic filling time, which worsens aortic regurgitation 1
• RAS inhibitors (ACE inhibitors or ARBs) are preferred first-line agents for hypertension in aortic stenosis due to beneficial effects on LV fibrosis, blood pressure control, dyspnea reduction, and improved effort tolerance 1, 2, 3

Diuretic Overuse

• Diuretics should be used sparingly in patients with small LV chamber dimensions and LV hypertrophy, as excessive preload reduction can cause hemodynamic decompensation 1, 3

Delayed Intervention Pitfalls

Symptom Recognition Failures

• Failing to recognize subtle symptoms in elderly, sedentary patients with multiple comorbidities leads to delayed valve replacement and increased mortality 1
• Once symptoms appear (angina, dyspnea, syncope), survival decreases rapidly—symptomatic severe aortic stenosis has extremely poor prognosis without intervention 1, 4, 5
• Exercise stress testing should be performed when symptom status is uncertain, looking for exercise-induced angina, excessive dyspnea, dizziness, syncope, limited exercise capacity, or abnormal blood pressure response 1

Medical Therapy Misconceptions

• Medical therapy is not indicated for symptomatic severe aortic stenosis—valve replacement is the only effective treatment 1
• Statins are not indicated for preventing progression of aortic stenosis 1
• Patients maintained on medical therapy alone despite symptoms have 61.5% mortality at 30 months compared to 22-23% with valve replacement 5

Risk Assessment Errors

Incomplete Comorbidity Evaluation

• Failing to perform comprehensive geriatric assessment leads to suboptimal treatment decisions 1
• Essential assessments include frailty screening (gait speed over 5 meters—those with <0.5 m/s need further evaluation), 6-minute walk test, cognitive function testing, and activities of daily living 1
• Major comorbidities requiring evaluation: chronic kidney disease (eGFR <30 mL/min), severe pulmonary disease (oxygen dependence, FEV1 <50% predicted), active malignancy, cirrhosis, and neurological disorders 1

Coronary Disease Oversight

• Coronary angiography is indicated in all patients being considered for valve replacement, as coronary artery disease is present in 40-75% of TAVR candidates 1
• The Heart Valve Team must decide on coronary revascularization case-by-case, though recent data from PARTNER 2A suggests revascularization does not increase 2-year mortality risk 1

Low-Flow State Misinterpretation

• Both stroke volume index (<35 mL/m²) and ejection fraction must be considered—low flow predicts poor outcomes post-intervention regardless of EF 1
• Distinguishing truly severe aortic stenosis from pseudosevere stenosis requires careful evaluation: truly severe AS has AVA ≤1.0 cm² and peak velocity >4 m/s at any flow rate 1

Treatment Selection Pitfalls

TAVR vs. SAVR Decision-Making

• TAVR is recommended for prohibitive surgical risk (≥50% mortality or irreversible morbidity at 30 days) and is reasonable for high surgical risk (STS ≥8%) 1
• Surgical AVR remains standard for low-to-moderate risk patients (STS <3% for low risk) 1
• Anatomical factors favoring TAVR include prior mediastinal irradiation, porcelain aorta, chest wall abnormalities, and hostile mediastinum from previous surgery 1

Concurrent Valve Disease

• Moderate-to-severe mitral regurgitation complicates TAVR decisions—present in 20% of patients, with poor outcomes predicted by primary MV disease, atrial fibrillation, pulmonary hypertension, and reduced EF 1
• Secondary mitral regurgitation often improves after TAVR, but primary MV disease requires separate consideration 1

Life Expectancy Miscalculation

• Valve replacement should not be performed if life expectancy is <1 year or if other factors suggest futility 1
• Patients with oxygen-dependent COPD and FEV1 <30% predicted have poor life expectancy independent of aortic stenosis severity 1

Procedural Complications Underestimation

TAVR-Specific Risks

• Stroke occurs in 6-7% (higher than SAVR's 2%) 1
• Pacemaker insertion required in 2-43% depending on valve type (CoreValve 19-43% vs. Sapien 2-9%) 1
• Paravalvular aortic regurgitation and access complications (17%) are significant concerns 1

SAVR-Specific Risks

• Mortality increases to 3-5% when combined with CABG 1
• Prolonged ventilation occurs in 11% of cases 1

Consultation Failures

• Cardiology consultation or co-management is mandatory for hypertension management in moderate-to-severe aortic stenosis 1, 2
• All treatment decisions should involve a multidisciplinary Heart Valve Team including cardiac surgery, interventional cardiology, cardiac imaging, anesthesiology, and geriatrics 1