In the absence of symptoms, the risk of sudden death in severe aortic stenosis is said to be lower than the risks associated with valve replacement.1-3 By contrast, without surgery, the median survival is 4.5 years with angina, 2.6 years with syncope, and less than 1 year with heart failure.4 The problem is that a proportion of these deaths occur early after the onset of symptoms. Unless investigation and surgery can be performed very quickly, death, whether sudden or not, is still unacceptably common in severe aortic stenosis.

The reported cumulative risk of sudden death varies between 0–9%,4 5 and the figure of 6% in the article in this issue of Heart 6 does not appear unrepresentative in comparison with earlier data.7 8 It is possible that some of these patients had symptoms that went unrecognised, but even in studies designed with careful follow up, the mortality is 3–4% very soon after the onset of symptoms.5 9 10 Furthermore, …