Table of contents
Aortic stenosis
What's new
Updated 2021 AHA/ACC and ESC/EACTS guidelines for the diagnosis and management of aortic stenosis.
Background
Overview
Definition
AS is a chronic fibrocalcific disease that results in narrowing of the aortic valve.
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Pathophysiology
AS is caused by the interplay of structural (e.g., bicuspid aortic valve), hereditary (e.g., genetic polymorphisms of lipoprotein A gene), and acquired (e.g., progressive age-related calcification, rheumatic valve disease) factors. Turbulent flow through a stenotic aortic valve causes endothelial damage, with subsequent subendothelial inflammation and accumulation of oxidized lipoproteins, and leads to deposition of calcium on the valve with progression of stenosis.
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Epidemiology
The prevalence of AS in the US is estimated at 400 persons per 100,000 population. The incidence of AS-related admissions in the US is estimated at 9.5-26 cases per 100,000 patient-years.
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Disease course
AS results in obstruction to the ejection of blood the left ventricle, with resultant signs and symptoms of left-sided HF.
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Prognosis and risk of recurrence
The overall survival of elderly patients with severe AS is 3 years from the onset of symptoms. In patients with severe, symptomatic AS who are at prohibitive risk for aortic valve replacement, the 1-year and 5-year mortality rates are 50% and > 90%, respectively.
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Guidelines
Key sources
The following summarized guidelines for the evaluation and management of aortic stenosis are prepared by our editorial team based on guidelines from the European Society of Hypertension (ESH 2023), the American Heart Association (AHA/ACC 2021), and the European Society of Cardiology (ESC/EACTS 2021)....
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Diagnostic investigations
TTE
As per ACC/AHA 2021 guidelines:
Obtain TTE for accurate diagnosis of the cause of AS, assessment of hemodynamic severity, measurement of LV size and systolic function, and determination of prognosis and timing of valve intervention in patients with signs or symptoms of AS.
A
Consider calculating the ratio of the outflow tract to aortic velocity to further define severity in patients with suspected low-flow, low-gradient severe AS with normal or reduced LVEF (stages D2-D3).
C
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Dobutamine stress testing
Exercise stress testing
Cardiac CT
Diagnostic procedures
Coronary angiography
As per EACTS/ESC 2021 guidelines:
Obtain coronary angiography before valve surgery in patients with severe valvular heart disease and any of the following:
history of CVD
suspected myocardial ischemia
LV systolic dysfunction
age > 40 for males
postmenopause
≥ 1 cardiovascular risk factors
B
Consider obtaining coronary CTA as an alternative to coronary angiography before valve surgery in patients with severe valvular heart disease and low probability of coronary artery disease.
C
Medical management
Antihypertensive therapy
As per ESH 2023 guidelines:
Use the same BP thresholds, targets, and drug treatment strategies in patients with AS as for the general population with hypertension.
B
Lower BP more cautiously to avoid an excessive fall in BP and recurrent syncope in patients with high-grade AS, particularly with a history of syncope.
B
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Statin therapy
Therapeutic procedures
Surgical interventions
Aortic valve replacement, risk assessment: as per ACC/AHA 2021 guidelines, Calculate individual risks for specific surgical and/or transcatheter procedures, using on-line tools when available, in patients with valvular heard disease when an intervention is contemplated, and discuss those risks before the procedure as a part of a shared decision-making process.
B
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Aortic valve replacement (indications)
Aortic valve replacement (choice of approach)
Aortic valve replacement (choice of valves)
Specific circumstances
Pregnant patients: as per ACC/AHA 2021 guidelines, Consider performing valve intervention before pregnancy in asymptomatic female patients with severe AS (aortic velocity ≥ 4.0 m/s or mean pressure gradient ≥ 40 mmHg, stage C) considering pregnancy.
C
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Patients with AF
Patients with coronary artery disease
Patients undergoing cardiac surgery for other indications
Patients undergoing non-cardiac surgery
Preventative measures
Prevention of infective endocarditis
As per ACC/AHA 2021 guidelines:
Consider administering antibiotic prophylaxis before dental procedures (involving manipulation of gingival tissue, manipulation of the periapical region of teeth, or perforation of the oral mucosa) in patients with valvular heart disease having any of the following:
prosthetic cardiac valves, including transcatheter-implanted prostheses and homografts
prosthetic material used for cardiac valve repair, such as annuloplasty rings, chords, or clips
previous infective endocarditis
unrepaired cyanotic congenital heart disease or repaired congenital heart disease, with residual shunts or valvular regurgitation at the site of or adjacent to the site of a prosthetic patch or prosthetic device
cardiac transplant with valve regurgitation attributable to a structurally abnormal valve
C
Do not administer antibiotic prophylaxis for non-dental procedures (such as TEE, EGD, colonoscopy, or cystoscopy) in the absence of active infection in patients with valvular heart disease at high risk of infective endocarditis.
D
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Secondary prevention of rheumatic fever
Follow-up and surveillance
Indications for referral
As per ACC/AHA 2021 guidelines:
Evaluate patients with severe valvular heart disease by a multidisciplinary heart valve team when intervention is considered.
B
Consider consulting with or referring to a primary or comprehensive heart valve center when discussing treatment options for:
asymptomatic patients with severe valvular heart disease
patients likely to benefit from valve repair versus valve replacement
patients with multiple comorbidities considered for valve intervention
C
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Post-intervention serial imaging
Post-intervention palliative care