Introduction

Aortic stenosis is the archetypal heart valve disease with which many doctors, cardiologists or otherwise, retain the most familiarity. The global healthcare burden of aortic stenosis continues to rise, yet it remains one of the last major cardiovascular diseases for which we have no preventative or disease-modifying medical therapy. Aortic valve replacement is the only ‘curative’ intervention and carries attendant risks, both peri-procedural and remote. Thus, the decision to offer intervention must be carefully considered and taken with the final objective that governs most treatments in mind: to improve symptoms or prognosis. There is also substantial debate surrounding the optimal timing of intervention. Intervene too early and patients may be unnecessarily exposed to the risks of valve replacement. Intervene too late and some patients may sustain irreversible cardiac damage that is associated with an increased risk of heart failure and death.

Valve replacement in symptomatic patients with severe aortic stenosis is usually uncontroversial, given their poor prognosis and the strong probability of improving their quality of life. Decisions regarding the management of patients with asymptomatic, isolated, severe aortic stenosis, however, are more complex. In this group, the predominant purpose of intervention would be to improve prognosis. In the absence of robust data, standard care in most cases has remained close observation, usually until symptoms develop.1–3 Implicit in this strategy is the concept that patients with asymptomatic severe aortic stenosis have a very good prognosis, and that there is consequently no net benefit to aortic valve replacement.

However, this paradigm has latterly become the subject of scrutiny for several reasons. Symptom assessment is frequently challenging in elderly, …