Watchful waiting care or early intervention in asymptomatic severe aortic stenosis: Where we are

Comparing Early Intervention to Watchful Waiting: A Review on Risk Stratification and Management in Asymptomatic Aortic Stenosis

Aortic stenosis is a progressive condition with substantial implications for morbidity and mortality. In recent years, attention has shifted toward risk stratification and the development of individualized management plans to optimize treatment outcomes. The management of asymptomatic patients has become a topic of significant controversy, as emerging studies challenge traditional watchful waiting guidelines and propose the potential benefits of early intervention. While early intervention may reduce overall morbidity and mortality in this patient population, the associated procedural risks remain a critical consideration. This review seeks to analyze the existing literature, offering an updated perspective on patient risk stratification and evidence evaluating both management approaches.

Prognostic Value and Safety of Serial Exercise Echocardiography in Asymptomatic Severe Aortic Stenosis

BACKGROUND

The prognostic value of serial exercise echocardiography (EEC) in asymptomatic severe aortic stenosis is unknown. We sought to evaluate the safety and utility of monitoring patients with asymptomatic severe aortic stenosis by annual EECs to refer them to aortic valve replacement (AVR) or to keep them under follow-up.

METHODS AND RESULTS

The cohort comprised 196 patients, with a normal screening EEC and a minimal follow-up of 18 months. Follow-up was planned until there was an indication for AVR, based on a resting transthoracic echocardiography at 6 months and then every year, and an EEC at 1 year and then every year (alternating resting transthoracic echocardiography and EEC every 6 months). During follow-up, patients were referred to AVR if they reported symptoms, if rest transthoracic echocardiography was positive (left ventricular dysfunction, aortic maximal velocity ≥5 m/s, or severe valve calcification with aortic maximal velocity progression ≥0.3 m/s per year) or if EEC was positive (occurrence during exercise of any aortic stenosis-related symptoms, significant ventricular arrhythmias, a drop or an insufficient rise (<20 mm Hg) in systolic blood pressure from baseline, or a left ventricular dysfunction). Among the 196 patients (76% men, aged 76.1±11.1 years), a mean 2.85±1.22 EECs were conducted. There were no serious complications during any of the EECs. Each serial transthoracic echocardiography at rest and each EEC yielded 0%-22% and 23.5%-50% of positive results, respectively, leading to AVR. We delayed AVR by a mean of 2.93±1.95 years after the screening EEC. No cardiac-related death or sudden death was reported during the study.

CONCLUSIONS

Our findings demonstrate the safety and prognostic utility of serial EECs in the management of patients with asymptomatic severe aortic stenosis to guide timely AVR.

2023 Korean Society of Echocardiography position paper for diagnosis and management of valvular heart disease, part I: aortic valve disease

This manuscript represents the official position of the Korean Society of Echocardiography on valvular heart diseases. This position paper focuses on the clinical management of valvular heart diseases with reference to the guidelines recently published by the American College of Cardiology/American Heart Association and the European Society of Cardiology. The committee tried to reflect the recently published results on the topic of valvular heart diseases and Korean data by a systematic literature search based on validity and relevance. In part I of this article, we will review and discuss the current position of aortic valve disease in Korea.

How to Improve Clinical Outcomes and Reduce Cardiovascular Risk in Older People with Cardiovascular Disease: Bridging Evidence Gaps

The geriatric population is greatly impacted by cardiovascular disease. Thus, it becomes essential to 'geriatricise' the cardiologist through the dissemination of geriatric cardiology. In the early days of geriatric cardiology, it was discussed whether it was simply cardiology 'well done'. Today, 40 years later, it seems clear that this is indeed the case. Patients with cardiovascular disease usually have several chronic conditions. Clinical practice guidelines often address a single condition and do not provide sufficient guidance for patients with multimorbidity. There are several evidence gaps regarding these patients. Physicians and members ofthe care team need a multidimensional understanding ofthe patient to better promote the optimisation of care. It is important to understand that ageing is inevitable, heterogeneous and increases vulnerability. Caregivers must know how to assess elderly patients in a multidomain practical way and how to recognise the factors that may have implications on treatment.

Stress echocardiogram in asymptomatic severe aortic stenosis

Aortic stenosis (AS) is one of the most common adult valve diseases. Therefore, current guidelines recommend prompt aortic valve intervention once symptoms occur. However, AS is predominantly a disease of the elderly, and these people may be underreporting their symptoms, have other comorbidities, or have a low level of exertion at the baseline or they might make a subconscious adjustment of their activities. Hence, stress testing can be a vital and objective tool to uncover their symptoms and prognosticate.