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Exercise testing has a long but largely forgotten pedigree in the assessment of patients with aortic stenosis. Before the development of echocardiography, a blunted rise in systolic blood pressure and the development of ST segment depression on an ECG during exercise were used to differentiate severe from more mild stenosis in children.1 In adults, ST segment depression is not sufficiently well correlated with coronary disease to be clinically useful.2 ,3 However the symptomatic and blood pressure responses to exercise may aid the timing of surgery in patients with equivocal or no symptoms.
Why is an objective assessment of symptoms necessary?
The prognosis in asymptomatic severe stenosis is widely regarded as too good to justify prophylactic surgery. However, as soon as symptoms develop, survival falls sharply and 10% of patients die within the first few months.4 ,5 This figure is far higher than the surgical risk of isolated aortic valve replacement which, even in unselected patients of all ages, was 4.4% in the UK during 1995–96 (Society of Cardiothoracic Surgeons, UK Cardiac Surgical Register). In a study advocating a conservative approach4 three of 113 apparently asymptomatic patients died within three months of developing symptoms before these were brought to the attention of their physician. Furthermore Lund et al reported that seven of 99 symptomatic patients died on a six month waiting list.5 It is possible that an earlier warning of the development of symptoms using treadmill exercise testing might have saved some of these patients. Otto et alfound that three of 104 apparently asymptomatic patients with all grades of …