Predicting Outcome in Patients With Asymptomatic Aortic Stenosis

Although the annual risk of cardiovascular mortality has been well described for individuals with symptomatic aortic stenosis, the morbidity and mortality for those with asymptomatic severe aortic stenosis is not as well known. Currently the American Heart Association/American College of Cardiology recommends a “watchful waiting” strategy for those with asymptomatic aortic stenosis.1 This involves clinical examinations every 6 to 12 months and annual echocardiograms; however, it is unclear what to do with these data in the patient who remains asymptomatic. The asymptomatic patient is generally not referred for aortic valve replacement surgery until the development of symptoms (unless concurrent coronary artery bypass grafting is required or if systolic dysfunction develops).Article see p 69 Approximately 30% of asymptomatic patients will develop symptoms (angina, heart failure, syncope) within 2 years of diagnosis.2,3 For those patients who do not develop symptoms, the risk of sudden cardiac death is less than 1% per year, assuming that patients are well monitored for the development of symptoms.2,3 Although angina and syncope are relatively easy symptoms to elicit, manifestations of heart failure may be subtle. This is particularly true because many of these patients are elderly and attribute reduced exercise capacity to be part of the normal aging process or “slowing down.” Vigilance and careful attention to a patient’s history are important components of the regular evaluation of patients with aortic stenosis. However, even careful attention to the history may not predict sudden death in patients with severe aortic stenosis. The reluctance to perform surgery earlier than necessary is driven by the morbidity of cardiac surgery and a mortality rate for aortic valve surgery of approximately 3% to 5%, even in patients younger than 70 years.4 Thus for truly asymptomatic patients, the risk of potential complications like sudden cardiac death and irreversible …