Treatment of Aortic Calcification
There is no medical therapy proven to prevent or delay aortic valve calcification progression; treatment focuses on cardiovascular risk factor modification for mild disease and aortic valve replacement for severe symptomatic stenosis. 1
Medical Management: Risk Factor Modification Only
Statins do not slow progression of calcific aortic stenosis despite initial promise from retrospective studies. 2 Three major randomized controlled trials (SALTIRE, SEAS, and ASTRONOMER) definitively demonstrated that statin therapy fails to reduce progression of aortic valve stenosis, even though patients in these trials had moderate to severe stenosis at baseline with high levels of valve calcification. 2, 1, 3
However, cardiovascular risk factor modification remains essential:
Implement aggressive blood pressure control, lipid management with statins (for atherosclerotic disease prevention, not valve disease), diabetes control, and smoking cessation. 1, 4 While statins don't affect valve calcification itself, they reduce coronary events and stroke risk in patients with valvular calcification. 4
Evaluate and modify cardiac risk factors to prevent concurrent coronary artery disease, which commonly coexists with aortic valve disease. 2
Avoid excessive calcium intake from phosphate binders (relevant in chronic kidney disease patients), as calcium loads exceeding 2,000 mg/day are associated with progressive vascular and valvular calcification. 2
Surveillance Strategy Based on Severity
The intensity of monitoring depends on stenosis severity 1:
Mild stenosis: Yearly clinical evaluation with echocardiography every 3-5 years 1, 4
Moderate stenosis (mean gradient 30-50 mmHg, valve area 1.0-1.5 cm²): Annual clinical follow-up with echocardiography every 6-12 months 1
Severe stenosis with asymptomatic status (peak aortic jet velocity >4 m/s): Re-evaluation every 6 months clinically and echocardiographically, monitoring for symptom development or hemodynamic progression (velocity increase >0.3 m/s per year) 1
Exercise testing in asymptomatic patients with severe stenosis is relatively safe and can unmask limited exercise capacity, abnormal blood pressure responses, or exercise-induced symptoms. 2 Patients with abnormal exercise tests have only 19% symptom-free survival at 2 years compared to 85% in those with normal tests. 2
Definitive Treatment: Aortic Valve Replacement
Aortic valve replacement (AVR) is the only effective treatment for severe symptomatic aortic stenosis. 1, 5
Clear Indications for AVR:
Symptomatic severe aortic stenosis regardless of age or surgical risk 1
Asymptomatic severe stenosis with left ventricular systolic dysfunction (LVEF <50%) 1
Asymptomatic severe stenosis with abnormal exercise test showing symptoms, hypotension, or limited exercise capacity 1
Choosing Between Surgical AVR (SAVR) and Transcatheter AVR (TAVR):
Age and life expectancy drive the decision 1:
Age <65 years or life expectancy >30 years: Surgical AVR is recommended (Class IA) due to superior long-term durability 1
Age 65-80 years: Either SAVR or TAVR is appropriate after shared decision-making about valve durability versus patient longevity 1
Age >80 years or life expectancy <10 years: TAVR is preferred over SAVR if transfemoral access is feasible (Class IA) 1, 5
Contraindications to AVR:
Do not proceed with AVR when 1:
- Life expectancy <1 year from comorbidities
- Moderate to severe dementia
- Bedbound status or inability to perform most activities of daily living
- End-stage organ failure (renal, liver, lung disease, or malignancy) where intervention is futile
- Extreme frailty limiting likelihood of functional recovery
Special Considerations
Physical activity restrictions depend on stenosis severity 2:
Mild stenosis: No restrictions; competitive sports participation allowed 2
Moderate to severe stenosis: Avoid competitive sports involving high dynamic and static muscular demands, though other exercise forms can be performed safely after exercise testing 2
Coronary angiography is recommended before AVR in patients at risk for coronary artery disease to identify concurrent disease requiring revascularization. 2
Common Pitfalls to Avoid
Do not prescribe statins specifically to slow valve calcification progression—this approach has been definitively disproven. 2, 1, 3
Do not delay AVR in symptomatic patients—the onset of symptoms portends predictably high mortality without intervention. 5
Do not perform exercise testing in symptomatic patients due to high complication risk. 2
In chronic kidney disease patients, limit total calcium intake from diet and binders to prevent accelerated vascular and valvular calcification. 2