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This editorial refers to ‘Exercise testing to stratify risk in aortic stenosis’† by P. Das et al. , on page 1309 In contrast to symptomatic aortic stenosis (AS), asymptomatic AS has been shown to have a relatively good outcome even if it is haemodynamically severe.1,2 From the current data, it appears unlikely that the potential benefit can outweigh the risk of surgery and the long-term risk of prosthesis related complications in all patients. Surgery is, therefore, not generally recommended in AS before symptom onset.3 The management of asymptomatic AS has, nevertheless, remained controversial for several reasons: sudden death in truly asymptomatic patients has been reported to be extremely rare with an incidence of <1% per year.1,2 However, patients frequently do not present immediately when symptoms develop and mortality has been reported to be quite significant already within the following month after symptom onset.1 In addition, mortality rates up to 7% have been reported for symptomatic patients who must wait for surgery for several months.4 Finally, operative mortality is significantly higher in symptomatic, when compared with asymptomatic, patients.5 Thus, the ideal approach would be to refer patients for surgery just before symptom onset. Besides the finding of a reduced systolic left ventricular function (which is extremely rare in asymptomatic AS), current American3 and European6 practice guidelines list an abnormal response to exercise as an acceptable indication for surgery in asymptomatic patients (class IIa). However, there are few data to support these recommendations and particular uncertainty remains how to define criteria for an abnormal exercise response that justifies surgical referral.Of the few studies that evaluated exercise testing in asymptomatic AS, the work by Amato et al. 7 provided so far the most helpful information with regard to clinical management. They … *Corresponding author. Tel: +43 1 40400 4614; fax: +43 1 4081148. E-mail address : helmut.baumgartner{at}meduniwien.ac.at

european heart journal

Management of asymptomatic aortic stenosis: how helpful is exercise testing?The opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal or of the European Society of Cardiology.