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Clinical Crossroads |

Asymptomatic Aortic Stenosis in the Elderly:  A Clinical Review

Warren J. Manning, MD, Discussant1
[+] Author Affiliations
1Cardiovascular Division, Department of Medicine, and Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
JAMA. 2013;310(14):1490-1497. doi:10.1001/jama.2013.279194.
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Published online

Importance  Aortic stenosis is the most common form of valvular heart disease. Progression of aortic stenosis is very slow and highly variable. Decisions about when to perform valve surgery are made by subjective assessment of patient symptoms and objective measures of the valve and ventricular function by transthoracic echocardiography.

Objective  To review current concepts regarding the development, progression, and assessment of aortic stenosis; the appropriate monitoring intervals for transthoracic echocardiography; and the indications for valve procedures.

Evidence Review  Guidelines and literature search.

Findings  Angina, exertional syncope, and heart failure are key symptoms indicating a need for intervention. The frequency of valvular monitoring by transthoracic echocardiography is guided by the disease severity. Despite evidence of severe disease, valve procedures can safely be deferred if patients experience no symptoms and have normal left ventricular ejection fraction. Asymptomatic patients with severe aortic stenosis may subconsciously curtail their activities to avoid symptoms. Apparently, asymptomatic patients can undergo a carefully monitored exercise stress test to confirm both their asymptomatic status and hemodynamic response to exercise. Bioprosthetic valves are a good replacement alternative for older patients who are good surgical candidates and who have no need for warfarin therapy. For patients who are at high or very high risk of cardiac surgery, transcutaneous aortic valve implantation is an increasing available and preferred over medical management.

Conclusions and Relevance  Asymptomatic patients with severe aortic stenosis require frequent monitoring of their subjective symptoms combined with objective measurement of aortic valve gradient and ventricular function by transthoracic echocardiography. Although conventional surgical replacement remains the mainstay of therapy for aortic stenosis, transcutaneous aortic valve implantation options are evolving.

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Figure 1.
Dr T's Transthoracic Echocardiogram Continuous Wave Color Doppler Results, August 2008 and January 2009
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Figure 2.
Normal and Stenotic Aortic Valve Morphologies

aMost common congenital cardiac anomaly in adults (men > women)1; also occurs secondary to thoracic aorta anomalies (aneurysm, dissection, or coarctation)

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Figure 3.
Algorithm for Management of Severe Aortic Stenosis

Adapted from Bonow et al20 and Vahanian et al.21 BP indicates blood pressure and LVEF, left ventricular ejection fraction

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