Medical management of symptomatic aortic stenosis
- 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
- Stephanie Cooper, MD
Stephanie Cooper, MD
- Clinical Assistant Professor of Medicine
- University of Washington
Aortic valve replacement (AVR) is the mainstay of treatment of symptomatic aortic stenosis (AS). AVR offers substantial improvements in symptoms and life expectancy. Medical therapy may not prolong life in patients with AS and has limited utility in treating symptoms.
In patients who are candidates for surgical intervention and are awaiting surgery, medical therapy to optimize hemodynamics in the pre-operative setting may be needed. However, when severe symptoms are present, it may be prudent to admit the patient to the hospital and perform surgery urgently, as there is a high risk of cardiac death once severe symptoms are present.
Longer-term palliative medical management of symptomatic AS is appropriate for patients who are not candidates for aortic valve surgery due to coexisting medical conditions and in patients who have refused AVR. Transcatheter AVR (TAVR) allows intervention in some patients who are at too high risk to undergo surgical AVR, but in others, TAVR may not be possible due to anatomic factors or may be futile due to a high level of comorbidities or frailty.
This topic will discuss medical management of patients with symptomatic AS and possible indications for aortic valvuloplasty. Indications for AVR, surgical and transcatheter methods of AVR, and management of asymptomatic AS are discussed separately. (See "Indications for valve replacement in aortic stenosis in adults" and "Choice of prosthetic heart valve for surgical replacement" and "Medical management of asymptomatic aortic stenosis in adults" and "Transcatheter aortic valve replacement: Indications and outcomes".)
Aortic valve replacement (AVR) is recommended for patients with symptomatic aortic stenosis (AS). (See "Indications for valve replacement in aortic stenosis in adults".) However, patients with symptomatic AS in the following settings may require temporary or indefinite medical management.
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- Comorbid conditions
- High-risk patients
- Patient refusal
- Patients awaiting valve replacement
- MEDICAL MANAGEMENT
- Severe symptomatic inoperable AS
- - General considerations
- - Management of loading conditions and symptoms
- - Prevention and treatment of concurrent conditions
- Medical management in patients awaiting aortic valve replacement
- - Critically ill patients awaiting valve replacement
- POSSIBLE INDICATIONS FOR AORTIC BALLOON DILATION
- ROLE OF PALLIATIVE CARE
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS