Early treatment of patients with severe aortic stenosis may be preferable to the standby and waiting approach

Patients with severe, symptomless aortic stenosis may benefit more from an aggressive early valve replacement strategy than from a conservative watch-and-hold approach, according to new research published today. line in The annals of thoracic surgery.

"We know that surgery carries a low risk and that's one of the reasons that caused the patient to feel the symptoms," said S. Chris Malaisrie, MD, of Northwestern Medicine in Chicago. "However, our data confirm the role of early valve replacement in the treatment of asymptomatic severe aortic stenosis."

Dr. Malaisrie and his colleagues evaluated echocardiogram data from Northwestern Medicine from January 2005 to December 2013. The researchers identified 265 patients with severe aortic stenosis who were asymptomatic. Among these patients, the replacement of the aortic valve was recommended in 104 patients (39%), while vigilant waiting was suggested in 161 (61%).

The researchers found that two years after the recommended approach, survival in the AVR group was 92.5%, compared with 83.9% in the WW group. In addition, the probability of WW patients dying or undergoing surgery is 43.9% at two years. Although this study has highlighted a "safe" period for WW (up to one year), data collected after two years suggest that early use of AVR has an advantage.

"For the AVR and WW groups, having an AVR was badociated with significantly higher overall survival," said Dr. Malaisrie. "It is important for patients to know that severe aortic stenosis, even in the absence of symptoms, results in poor results if it is not treated."

Aortic stenosis, one of the most serious and common heart disease in the United States, occurs when the aortic heart valve narrows, preventing the valve from opening completely. The blood flow into the main artery of the body (aorta) is blocked or reduced and the heart is forced to work harder when it pumps blood into the body. Symptoms badociated with severe aortic stenosis include shortness of breath, chest pain or tightness, fainting, dizziness, palpitations, or heartbeat.

"If they are confirmed, these results would reflect a potentially dramatic difference in survival affecting tens of thousands of Americans," said Todd K. Rosengart, MD, of Houston's Baylor College of Medicine, who said: He did not participate directly in this study. "The results of this study suggest that a fundamental change is needed in the way we treat patients with narrowing of the aortic valve.

"This breakthrough would reflect what we already know and practice in treating the disease of the other major heart valve, the mitral valve – which you do not need and you probably should not wait until you reach it. 39; at the onset of symptoms to correct a major dysfunction of the heart valves. ", Added Dr. Rosengart.

The American Heart Association's and the American College of Cardiology's clinical guidelines recommend "active surveillance" in asymptomatic patients unless stress tests can expose the symptoms. In this study, less than 30% of patients were referred for stress tests. Dr. Malaisrie agrees that stress tests can be a critical differentiator in early surgery in asymptomatic patients. It encourages clinicians to continue to use it when determining treatment strategies.

Historically, the management of asymptomatic patients includes the accepted practice of WW and the delay of AVR until the development of symptoms. However, the WW strategy requires that patients recognize and promptly report all symptoms and that they return to the hospital for a follow-up echocardiogram.

"The onset of symptoms can often be subtle and patients can attribute significant changes to old age without informing their doctor," said Dr. Malaisrie. "They must know the symptoms and immediately report them to the heart team.In addition, if patients do not follow the recommended imaging, the progression of stenosis and signs of heart failure may be failed. "

For patients with severe and symptomatic aortic stenosis, traditional treatment consists of a minimally invasive AVR, whether surgical or transcatheter, which reduces the risks badociated with open-heart surgery and reduces the time to recovery, explained Dr. Malaisrie, making it a viable option for earlier treatment of patients with no symptoms.

"Patients with asymptomatic severe aortic stenosis should closely follow their cardiac team members and discuss all available treatment options," said Dr. Malaisrie. "We hope that our study will influence guidelines and discussions regarding the early treatment of severe aortic stenosis, particularly in asymptomatic patients.