Asymptomatic Aortic Stenosis


Eugene Braunwald
Brigham and Women's Hospital
Boston, MA, USA

Recent case series have identified groups of asymptomatic aortic stenosis patients at very high risk of becoming symptomatic and requiring valve replacement. Physicians can identify high-risk asymptomatic patients using frequent clinical examination, exercise tolerance testing, and echocardiography.

Management of aortic stenosis in the asymptomatic patient is a clinical challenge. Patients with non-severe stenosis should receive follow-up evaluation every 1 to 2 years. However, if the patient's stenosis is severe, then the patient may be at high risk, and may qualify for aortic valve replacement.

If the asymptomatic patient with severe stenosis is going to receive other cardiac surgery, such as coronary artery bypass graft, then current guidelines support aortic valve replacement. The American Heart Association/American College of Cardiology published these guidelines in 1998.

Otherwise, physicians should consider the natural history of the disease. Recent reviews of case series have identified groups of clinically asymptomatic patients at very high risk of becoming symptomatic in a brief period of time.

For example, the rate of increase in aortic jet velocity is a predictor of clinical outcome. An important predictor of event-free survival is severity of valve calcification on electrocardiogram.

Based on these and other findings, clinicians can identify patients who may benefit from earlier aortic valve replacement. The main tools include frequent clinical examination, exercise tolerance testing, and echocardiography.

Dr. Braunwald suggested an algorithm for the management of asymptomatic patients with severe aortic stenosis:

*The patient scheduled for other cardiac surgery would already qualify for the aortic valve.

* If not, the physician can perform an exercise tolerance test under careful observation.
The patient who becomes hypotensive or symptomatic should receive aortic valve replacement. If the exercise test is negative, go to the next step.

* If the patient has a severely calcified valve and an increasing aortic jet velocity, Dr. Braunwald said he would strongly consider valve replacement. But if the patient does not have one of these risk factors, the physician can schedule a follow-up clinical exam and exercise tolerance test every six months.

An intriguing future possibility is that statins may help arrest the progression of aortic stenosis. Novaro and others recently published this report in the October 30, 2001 edition of Circulation. These data are the first to suggest that this important valve abnormality may respond to medical treatment.


Reporter: Andrew Bowser