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 AVI (TAVI) allows intervention in some patients who are at too high risk to undergo surgical AVR, but in others, TAVI 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 "Choice of therapy for symptomatic severe aortic stenosis".)
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.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Bach DS, Siao D, Girard SE, et al. Evaluation of patients with severe symptomatic aortic stenosis who do not undergo aortic valve replacement: the potential role of subjectively overestimated operative risk. Circ Cardiovasc Qual Outcomes 2009; 2:533.
- van Geldorp MW, van Gameren M, Kappetein AP, et al. Therapeutic decisions for patients with symptomatic severe aortic stenosis: room for improvement? Eur J Cardiothorac Surg 2009; 35:953.
- Bonow RO, Carabello BA, Chatterjee K, et al. 2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2008; 118:e523.
- Bonow RO, Nishimura RA, Thompson PD, Udelson JE. Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities: Task Force 5: Valvular Heart Disease: A Scientific Statement From the American Heart Association and American College of Cardiology. J Am Coll Cardiol 2015; 66:2385.
- Pibarot P, Dumesnil JG. New concepts in valvular hemodynamics: implications for diagnosis and treatment of aortic stenosis. Can J Cardiol 2007; 23 Suppl B:40B.
- Antonini-Canterin F, Huang G, Cervesato E, et al. Symptomatic aortic stenosis: does systemic hypertension play an additional role? Hypertension 2003; 41:1268.
- Carabello BA, Paulus WJ. Aortic stenosis. Lancet 2009; 373:956.
- Moreno PR, Jang IK, Newell JB, et al. The role of percutaneous aortic balloon valvuloplasty in patients with cardiogenic shock and critical aortic stenosis. J Am Coll Cardiol 1994; 23:1071.
- Khot UN, Novaro GM, Popović ZB, et al. Nitroprusside in critically ill patients with left ventricular dysfunction and aortic stenosis. N Engl J Med 2003; 348:1756.
- Zile MR, Gaasch WH. Heart failure in aortic stenosis - improving diagnosis and treatment. N Engl J Med 2003; 348:1735.
- Nishimura RA, Holmes DR Jr, Reeder GS. Percutaneous balloon valvuloplasty. Mayo Clin Proc 1990; 65:198.
- Lieberman EB, Bashore TM, Hermiller JB, et al. Balloon aortic valvuloplasty in adults: failure of procedure to improve long-term survival. J Am Coll Cardiol 1995; 26:1522.
- Percutaneous balloon aortic valvuloplasty. Acute and 30-day follow-up results in 674 patients from the NHLBI Balloon Valvuloplasty Registry. Circulation 1991; 84:2383.
- Litvack F, Jakubowski AT, Buchbinder NA, Eigler N. Lack of sustained clinical improvement in an elderly population after percutaneous aortic valvuloplasty. Am J Cardiol 1988; 62:270.
- Ferguson JJ, Garza RA. Efficacy of multiple balloon aortic valvuloplasty procedures. The Mansfield Scientific Aortic Valvuloplasty Registry Investigators. J Am Coll Cardiol 1991; 17:1430.
- Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014; 63:e57.
- Christ M, Sharkova Y, Geldner G, Maisch B. Preoperative and perioperative care for patients with suspected or established aortic stenosis facing noncardiac surgery. Chest 2005; 128:2944.
- Torsher LC, Shub C, Rettke SR, Brown DL. Risk of patients with severe aortic stenosis undergoing noncardiac surgery. Am J Cardiol 1998; 81:448.
- Allen LA, Stevenson LW, Grady KL, et al. Decision making in advanced heart failure: a scientific statement from the American Heart Association. Circulation 2012; 125:1928.
- Goodlin SJ. Palliative care in congestive heart failure. J Am Coll Cardiol 2009; 54:386.
- Goodlin SJ, Quill TE, Arnold RM. Communication and decision-making about prognosis in heart failure care. J Card Fail 2008; 14:106.
- Lauck S, Garland E, Achtem L, et al. Integrating a palliative approach in a transcatheter heart valve program: bridging innovations in the management of severe aortic stenosis and best end-of-life practice. Eur J Cardiovasc Nurs 2014; 13:177.
- 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