How should I interpret and manage an asymptomatic patient whose echocardiogram shows normal left ventricular size with preserved systolic function (ejection fraction ≈ 65 %), diastolic dysfunction, mild concentric left ventricular hypertrophy, mild left and right atrial enlargement, a trileaflet aortic valve that is thickened with restricted motion and peak/mean gradients of 25 mmHg and 13 mmHg (mild aortic stenosis), mild mitral annular calcification with mild mitral regurgitation, mild tricuspid regurgitation, normal estimated pulmonary artery systolic pressure (29 mmHg), and no pericardial effusion?

Management of Asymptomatic Patient with Mild Aortic Stenosis, Diastolic Dysfunction, and Mild Concentric LVH

This patient requires serial echocardiographic surveillance every 1–2 years, aggressive blood pressure control targeting <130/80 mmHg, and investigation into the underlying cause of severe left atrial enlargement, which is the most concerning finding on this echocardiogram despite preserved systolic function. 1, 2

Interpretation of Key Findings

Aortic Stenosis Assessment

• The peak gradient of 25 mmHg and mean gradient of 13 mmHg confirm mild aortic stenosis, which does not require intervention at this time 1
• Severe aortic stenosis is defined by mean gradient ≥40 mmHg or valve area <1.0 cm²; this patient falls well below these thresholds 1
• The thickened, restricted aortic valve represents aortic sclerosis progressing toward stenosis and requires monitoring for progression 1

Left Ventricular Function

• The ejection fraction of 65% is normal (normal ≥50–53%) and indicates preserved systolic function 1, 3
• Mild concentric left ventricular hypertrophy reflects chronic pressure overload, most commonly from hypertension, and is associated with impaired diastolic function even when systolic function remains normal 4, 5
• The combination of concentric hypertrophy with diastolic dysfunction indicates increased LV stiffness and elevated filling pressures during volume loading 1, 5

Diastolic Dysfunction and Atrial Enlargement

• The presence of diastolic dysfunction with mild bilateral atrial enlargement indicates chronically elevated left ventricular filling pressures 1, 6
• Diastolic dysfunction in the setting of concentric hypertrophy is characterized by impaired LV relaxation and reduced chamber compliance 7, 5
• Mild left and right atrial enlargement reflects chronic elevation of filling pressures and significantly increases risk for atrial fibrillation, stroke, and heart failure hospitalization 2
• The finding of bilateral atrial enlargement suggests the diastolic dysfunction has been present long enough to cause structural remodeling 2

Valvular Regurgitation

• Mild mitral regurgitation with mitral annular calcification is a common age-related finding that does not require intervention at this severity 1
• Mild tricuspid regurgitation is hemodynamically insignificant and the estimated PA systolic pressure of 29 mmHg is normal (normal <35–40 mmHg) 1, 2

Management Strategy

Identify Underlying Etiology

• Investigate the cause of diastolic dysfunction and atrial enlargement: chronic hypertension is the most common etiology, but also consider infiltrative cardiomyopathy, restrictive physiology, or occult valvular disease 2
• Obtain detailed history focusing on hypertension duration and control, diabetes, sleep apnea, and family history of cardiomyopathy 1
• Check BNP or NT-proBNP levels; elevation suggests hemodynamically significant diastolic dysfunction even in asymptomatic patients 1

Blood Pressure Management

• Aggressive blood pressure control to <130/80 mmHg is the cornerstone of therapy, as hypertension is the primary driver of concentric LVH and diastolic dysfunction 2, 3
• ACE inhibitors or ARBs are first-line agents as they reduce afterload, promote regression of LVH, and improve diastolic function 7
• Avoid excessive diuresis in isolated diastolic dysfunction, as these patients are preload-dependent; use diuretics only if volume overload develops 7

Aortic Stenosis Surveillance

• Serial echocardiography every 1–2 years is indicated for mild aortic stenosis to monitor for progression 1
• Educate the patient to report new symptoms: exertional dyspnea, chest pain, syncope, or reduced exercise tolerance 1
• Exercise stress testing is contraindicated if the patient becomes symptomatic, but can be considered now to assess functional capacity and symptomatic response 1

Monitoring for Heart Failure with Preserved EF

• This patient is at high risk for progression to HFpEF given the combination of diastolic dysfunction, concentric LVH, and atrial enlargement 1, 8
• If dyspnea or exercise intolerance develops, perform diastolic stress echocardiography to assess for abnormal elevation of filling pressures with exercise 1, 8
• Consider cardiopulmonary exercise testing if symptoms emerge to objectively quantify functional capacity 2

Follow-Up Echocardiography

• Repeat echocardiography in 6–12 months given the atrial enlargement, then annually if stable 2
• Earlier imaging is warranted if new symptoms develop, particularly dyspnea, palpitations, or reduced exercise tolerance 1, 2
• Serial assessment should track: aortic valve gradients and progression of stenosis, LV mass and wall thickness, atrial size, estimated filling pressures (E/e' ratio), and development of functional tricuspid regurgitation 1

Critical Pitfalls to Avoid

• Do not dismiss the significance of atrial enlargement simply because ejection fraction is normal; bilateral atrial enlargement indicates chronic hemodynamic stress and warrants investigation 2
• Do not label this as "normal diastolic function" when atrial enlargement is present; the structural remodeling itself confirms chronic diastolic dysfunction regardless of other parameters 1, 2
• Do not overlook the need for coronary evaluation if the patient is elderly (>70 years) or has cardiovascular risk factors, as coronary disease can coexist and contribute to diastolic dysfunction 9
• Avoid beta-blockers as monotherapy in isolated diastolic dysfunction, as they can worsen symptoms by preventing compensatory tachycardia; calcium channel blockers or ACE inhibitors are preferred 7
• Do not delay intervention if symptoms develop, as symptomatic mild aortic stenosis or symptomatic diastolic dysfunction both carry significantly worse prognosis than asymptomatic disease 1