Contemporary Workup and Management of Asymptomatic Patients with Severe Aortic Stenosis
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Valvular Heart Disease (J Dal-Bianco, Section Editor)
Contemporary Workup and Management of Asymptomatic Patients with Severe Aortic Stenosis Jasleen K Tiwana, MD Catherine M Otto, MD* Address * Division of Cardiology, Department of Medicine, University of Washington School of Medicine, Box 356422, 1959 NE Pacific St, HSB AA522, Seattle, WA, 98195, USA Email: [email protected]
Published online: 10 October 2020 * Springer Science+Business Media, LLC, part of Springer Nature 2020
Topical Collection on Valvular Heart Disease Keywords Asymptomatic I Severe aortic stenosis I Management I Evaluation I Biomarkers I Early intervention
Abstract Purpose of review Appropriate management of asymptomatic patients with severe aortic stenosis (AS) is increasingly debated given recent improvements in options for aortic valve replacement (AVR). The goal of this review is to provide an updated approach to evaluation and management of patients with asymptomatic severe AS and to discuss the rationale for early AVR. Recent findings Registry data, retrospective studies, and one small randomized controlled clinical trial suggest a mortality benefit to AVR before symptom onset, although larger randomized trials are needed given potential biases of observational data. Other promising approaches to risk stratification of asymptomatic adults with severe AS include cardiac biomarkers (such as serum B-type natriuretic peptide levels), left ventricular global longitudinal strain, and myocardial fibrosis detected on cardiac magnetic resonance imaging. Summary Routine close clinical follow-up, periodic imaging, patient education, and shared decision-making are essential in caring for asymptomatic patients with severe AS but there is not yet enough evidence to support early AVR in most patients. Ongoing clinical trials and evaluation of biomarkers will illuminate whether intervention before symptom onset will improve the length or quality of life in adults with severe AS.
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Curr Treat Options Cardio Med (2020) 22: 47
Introduction Disease overview The prevalence of calcific aortic stenosis (AS) increases with age, with severe AS affecting up to 3.4% of people 75 years of age or older [1, 2]. Moderate AS is even more common and typically progresses to severe AS within 5 to 10 years. At the time of diagnosis, 30–50% of patients with severe AS are asymptomatic [3, 4]. Morbidity and mortality are closely linked to AS disease severity and the emergence of symptoms in patients who initially are asymptomatic [5]. Generally, the goals of aortic valve replacement (AVR) for severe AS are to prolong life, reduce symptoms, and prevent heart failure long-term. Although AVR is clearly indicated in patients with symptoms from valve obstruction, the balance of risks and benefits is less clear in patients who are asymptomatic. After all, patients without symptoms will not have symptomatic benefit with AVR. The hypothesis that asymptomatic patients with severe AS may benefit from AVR before symptom onset is often referred to as “early AVR.” In addi
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