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This editorial refers to ‘Comparison of exercise testing and cardiovascular magnetic resonance-measured myocardial perfusion reserve for predicting outcome in asymptomatic aortic stenosis: the PRognostic Importance of MIcrovascular Dysfunction in Aortic Stenosis (PRIMID AS) study’, by A. Singh et al. doi:10.1093/eurheartj/ehx001. Degenerative aortic stenosis (AS) is one of the most common valvular diseases in developed countries.1 AS is a progressive disease for which the only effective treatment is surgical or transcatheter aortic valve replacement (AVR).2,3 Patients with mild to moderate AS require no specific valve treatment, whereas AVR is indicated in patients with severe symptomatic AS. The main conundrum in the management of AS relates to the timing of AVR in almost half of the patients who have severe AS but do not report clinical symptoms at the time of diagnosis.4 This uncertainty is mainly fed by the fact that no study has so far compared prospectively the outcomes in asymptomatic patients with severe AS undergoing watchful waiting and those undergoing AVR. Analysing all the previous studies reporting all-cause mortality in patients with asymptomatic AS who underwent AVR and those managed conservatively pointed to significant bias and data heterogeneity, preventing any valid conclusion.5 Delaying AVR in severe AS until symptoms appear represents for most clinicians the fear that patients may present with irreversible myocardial damage, sudden cardiac death, or a rapidly progressive disease, especially in the absence of appropriate monitoring.6 Hence, there is a crucial need to enable a prospective detection of patients with AS who will benefit from AVR before they become symptomatic. Based on the pathophysiological events occurring during valvular and myocardial remodelling in AS, several clinical, biological, and imaging parameters are currently being considered at different levels of evidence to help decision-making in asymptomatic severe AS.7Coronary microvascular dysfunction …

Coronary microvascular reserve and outcome in aortic stenosis: Pathophysiological significance vs. clinical relevance