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In the developed world, aortic stenosis (AS) is the commonest valve disease requiring surgery. AS is common in the elderly and up to 3% of subjects over 75 years of age may have severe disease.1 In the past decade the number of isolated aortic valve replacements (AVRs) performed in the USA and the UK has doubled. As the population in developed countries continues to age, it is predicted that the prevalence of AS will double in the next 20 years. Cardiologists and cardiac surgeons will increasingly face the dilemma of how to manage optimally this important group of predominantly elderly patients, many of whom will be asymptomatic and have been identified by the incidental finding of a systolic murmur or abnormal ECG.
The development of symptoms in severe AS heralds a malignant phase of the condition and prompt AVR results in a clear reduction in mortality, which is still apparent in the modern era, reflecting the lack of effective medical treatments.2 Surgery in this situation is universally regarded as a class I indication despite the absence of randomised controlled trials (RCTs).3 4 In contrast, the management of patients with severe AS in the absence of symptoms remains one of the most controversial areas in modern cardiology, reflected in differences in guidelines of the major cardiovascular societies.3 4 Currently the European Society of Cardiology (ESC)3 regards symptoms on exercise testing as …