Medical management of asymptomatic aortic stenosis in adults
- Catherine M Otto, MD
Catherine M Otto, MD
- Editor-in-Chief — Cardiovascular Medicine
- Section Editor — Cardiac Evaluation; Valvular Disease
- Professor of Medicine
- University of Washington
In individuals with normal aortic valves, the effective area of valve opening equals the cross-sectional area of the left ventricular outflow tract, which is about 3.0 to 4.0 cm2 in adults. As aortic stenosis (AS) develops, a minimal valve gradient is present until the orifice area becomes less than half of normal. The natural history of AS therefore begins with a prolonged asymptomatic period associated with minimal mortality.
Serial hemodynamic examinations in several studies show that progressive valve obstruction occurs in nearly all adults with calcific aortic valve disease once even mild valve obstruction is present (figure 1). Patients remain asymptomatic as aortic velocity increases and valve area decreases until the severity of obstruction results in an inadequate cardiac output with exercise leading to symptom onset. (See "Natural history, epidemiology, and prognosis of aortic stenosis", section on 'Risk factors for progression'.)
In general, symptoms in patients with AS and normal left ventricular systolic function rarely occur until the stenosis is severe as defined by valve area <1.0 cm2, aortic jet velocity over 4.0 m/sec, and/or mean transvalvular gradient exceeds 40 mmHg (table 1). However, many patients do not develop symptoms until even more severe valve obstruction is present, and some patients with less severe AS are symptomatic. (See "Clinical manifestations and diagnosis of aortic stenosis in adults", section on 'Complications'.)
The only effective treatment for severe symptomatic AS is valve replacement. In such patients who refuse or are not candidates for surgical intervention, therapeutic options are limited and of only marginal benefit. Percutaneous valve replacement may be an option for high-risk patients in the future; this approach is currently being evaluated in clinical trials. (See "Indications for valve replacement in aortic stenosis in adults" and "Medical management of symptomatic aortic stenosis" and "Percutaneous balloon aortic valvotomy".)
Among asymptomatic patients, there are no medical therapies that have been proven to delay progression of the leaflet disease. Although retrospective studies of statin therapy were promising, a large randomized prospective study demonstrated that statin therapy does not prevent disease progression. However, many patients have concurrent cardiac conditions that require therapy, including hypertension, coronary heart disease, atrial fibrillation, and left ventricular dysfunction.
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- SERIAL EVALUATION
- PREVENTION OF DISEASE PROGRESSION
- Hypercholesterolemia and statin therapy
- - Rationale
- - Statin trials
- - Statin conclusion
- Other potential preventative therapies
- ENDOCARDITIS PROPHYLAXIS
- CORONARY ARTERY DISEASE
- Risk factor reduction
- Symptomatic CAD
- PHYSICAL ACTIVITY AND EXERCISE
- ATRIAL FIBRILLATION
- HEART FAILURE
- CONCURRENT DISEASE OF THE AORTA
- NONCARDIAC SURGERY
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS