OBJECTIVE To evaluate the application of guidelines in the decision making process leading to medical or surgical treatment for aortic stenosis in elderly patients.

DESIGN Cohort analysis based on a prospective inclusive registry.

SETTING 205 consecutive patients (⩾ 70 years) with clinically relevant isolated aortic stenosis and without serious comorbidity, seen for the first time in the Doppler-echocardiographic laboratories of three university hospitals in the Netherlands.

RESULTS The initial choice was surgery in 94 patients and medical treatment in 111. Only 59% of the patients who should have had valve replacement according to the practice guidelines were actually offered surgical treatment. These were mainly symptomatic patients under 80 years of age with a high gradient. Operative mortality (30 days) was only 2%. The three year survival was 80% in the surgical group (17 deaths among 94 patients) and 49% in the medical group (43/111). Multivariate analysis showed that only patients with a high baseline risk, mainly determined by impaired left ventricular function, had a significantly better three year survival with surgical treatment than with medical treatment.

CONCLUSIONS In daily practice, elderly patients with clinically relevant symptomatic aortic stenosis are often denied surgical treatment. This study indicates that a surgical approach, especially where there is impaired systolic left ventricular function, is associated with better survival.