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Medical management of asymptomatic aortic stenosis in adults

Catherine M Otto, MD
Section Editor
William H Gaasch, MD
Deputy Editor
Susan B Yeon, MD, JD, FACC


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 exceeding 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 or with mixed stenosis and regurgitation are symptomatic. (See "Clinical manifestations and diagnosis of aortic stenosis in adults", section on 'Complications'.)

The only effective treatment for symptomatic severe AS is valve replacement (surgical aortic valve replacement [SAVR] or transcatheter aortic valve implantation [TAVI]). Choice of therapy in patients with symptomatic severe AS is discussed separately. (See "Choice of therapy for symptomatic severe aortic stenosis".)

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 meet criteria for statin therapy based on standard risk factor evaluation and should be treated according to guidelines. In addition, most adults with AS have concurrent cardiac conditions that require therapy, including hypertension, coronary heart disease, atrial fibrillation, and left ventricular dysfunction.

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Literature review current through: Nov 2017. | This topic last updated: Feb 28, 2017.
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