Stress testing is a cornerstone in the evaluation of patients with coronary artery disease and its results are always integrated into any clinical decisions. In contrast, valvular heart disease is usually considered static and its management relies upon resting evaluation only. However, most valve diseases have a dynamic component. Changes in loading conditions and contractility during a patient’s life may lead to alterations in the severity of lesions, good or poor ventricular contractile reserve, altered volume-dependent compliance of heart chambers, and ventricular arterial coupling. Thus, there may be a need for stress testing and imaging in this setting. Exercise testing in particular can induce symptoms, reveal the dynamics of the valve and the ventricle, and evaluate the changes in forward output, retrograde flow and pulmonary pressures. The current primary role of stress testing in valve disease is to provide an objective assessment of functional disability which is of the utmost importance in patients who often adapt and reduce their physical activity, thus masking their symptoms. The Euro Heart Survey on valvular disease recently showed that stress testing is underused in Europe, or used for inappropriate purposes.¹

The following questions will be addressed for each of the left valvular heart diseases:

• Who needs stress testing?

• How to test: which stress modality should be used?

• Which parameters should be measured and followed—in other words, should the valve, the ventricle, or both, be tested?

• How can the results help in the patient’s management?

AORTIC STENOSIS

Asymptomatic severe aortic stenosis

Who needs stress testing?

Valve replacement is required in the presence of symptoms and severe aortic stenosis. In such patients, stress testing is contraindicated. In contrast, exercise testing is recommended in asymptomatic patients with severe aortic stenosis. Exercise is strongly advocated in the European guidelines² and is a grade IIb recommendation in the American College of Cardiology/American Heart Association (ACC/AHA) 2006 guidelines. …