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- Aortic stenosis
- aortic valve replacement
- asymptomatic patients
- risk stratification
- exercise testing
The management of asymptomatic patients with aortic stenosis (AS) is a frequent situation, as attested by the 23% of patients in New York Heart Association (NYHA) functional class I referred for AS in the Euro Heart Survey on valvular disease.1 This is the consequence of an increased awareness of AS, which is the most frequent heart valve disease in western countries, and of the widespread use of echocardiography. Symptomatic severe AS is a class I recommendation for surgery in guidelines.2 3 Conversely, asymptomatic AS was initially considered as justifying only follow-up. A better insight into the prognosis of asymptomatic AS now makes it possible to identify asymptomatic patients with AS in whom intervention can be considered.
Natural history of asymptomatic aortic stenosis
The landmark paper of Ross and Braunwald published in 1968 reported a dramatic increase in the mortality of patients with AS after the onset of severe symptoms. For a long time this has been the rationale for not operating on patients with asymptomatic AS. However, this study from the pre-echo era did not include any evaluation of either AS severity or its left ventricular consequences. In addition, rheumatic AS was still prevalent and mean age at death was 63 years, which does not correspond to contemporary AS epidemiology.
Prospective studies focusing on asymptomatic AS have been performed since the 1990s and these have progressively led to an individualised prognostic assessment. From nine prospective series totalling 1125 asymptomatic patients, the linearised rate of sudden death is estimated at 0.8% per year (table 1).4–12 A series of 622 patients identified retrospectively reported a 0.3% yearly rate of sudden death over a mean follow-up of 5.4 years.13
At first sight, this could be an incentive for not intervening before symptom onset, since the …