The primary clinical marker for recommending aortic valve replacement (AVR) to a patient with severe aortic stenosis (AS) is the development of symptoms. Nonetheless, the recently updated clinical guidelines indicate that it is reasonable to consider AVR in patients with severe asymptomatic AS when accompanied by certain features, such as a very high transvalvular gradient or an abnormal exercise test.1 Of note, the US guidelines do not provide a recommendation for AVR in those with asymptomatic severe AS and an elevated B-type natriuretic peptide (BNP) level, whereas the European guidelines indicate the AVR may be considered in patients with a normal exercise test but ‘markedly’ elevated natriuretic peptide level.1 ,2

The challenge of accurately assessing whether symptoms are present is widely known.3 The most common early symptom from severe AS is exertional dyspnoea, but symptom onset may be insidious and ascribed to normal aging or physical deconditioning. As such, in cases where functional capacity and symptoms are uncertain, exercise testing is recommended.1 However, while a decline in systolic blood pressure is objective evidence of an abnormal exercise test, identifying abnormal exercise tolerance and whether limiting symptoms are cardiac in origin is often less clear.

In this context, the findings of Capoulade et al4 are particularly intriguing. They obtained resting and exercise echocardiographic and BNP measurements in 157 patients with severe asymptomatic AS and preserved EF. Their study …