Aortic stenosis

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

INITIAL

clinically unstable

1st line – medical therapy or balloon valvuloplasty

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1st line –

medical therapy or balloon valvuloplasty

The information in this treatment algorithm is largely based on recommendations from the American College of Cardiology/American Heart Association (ACC/AHA). For information on how recommendations from the UK National Institute for Health and Care Excellence (NICE) and the European Society of Cardiology/European Association for Cardio-Thoracic Surgery (ESC/EATC) differ, see Management Approach. Follow the recommended approach in your region.

All patients need to be stabilized prior to surgery or transcatheter aortic valve replacement (TAVR).

There has been concern that vasodilator therapy could be potentially dangerous, due to the possibility that a stenotic valve might permit only a fixed cardiac output, leading to hypotension. Vasodilator and beta-blocker therapy is not routinely given preoperatively on the day of surgery, although vasodilator therapy may be helpful for selected patients in closely monitored settings (e.g., ICU).

For patients with severe AS who are critically ill, need urgent noncardiac surgery, have cancer and an unclear long-term survival, are acutely symptomatic, or are in cardiogenic shock, balloon valvuloplasty is a reasonable option as a bridge to recovery and subsequent evaluation for surgical aortic valve replacement (SAVR) or TAVR.[26] This is a percutaneous procedure done in the cardiac catheterization lab in which a balloon is forcefully inflated across the aortic valve to relieve stenosis. Unfortunately, restenosis rates are high at 6 months and there is no shown improvement in mortality following valvuloplasty. However, patients do generally experience improvement in hemodynamics and symptoms, which may provide an opportunity for more definitive care.[74][Figure caption and citation for the preceding image starts]: Balloon valvuloplasty fluoroscopy film that demonstrates valvuloplasty balloon inflated across a calcified aortic valveFrom the collection of David Liff, MD, Emory University Hospital; used with permission [Citation ends]. com.bmj.content.model.Caption@3a3af52e

ACUTE

clinically stable: symptomatic

severe AS: age <65 years or life expectancy >20 years

1st line – surgical aortic valve replacement

Back

1st line –

surgical aortic valve replacement

The ACC/AHA guidelines recommend surgical aortic valve replacement (SAVR) for symptomatic and asymptomatic patients with severe AS who meet an indication for aortic valve replacement (AVR) and who are <65 years of age or have a life expectancy >20 years. This includes patients with an LVEF <50%.[26]

Prosthetic aortic valves used in surgical valve replacement may be mechanical or bioprosthetic.

AVR is recommended in symptomatic patients with severe AS, including those with low-flow/low-gradient severe AS with either a reduced left ventricular ejection fraction (LVEF) and persistent severe AS on low-dose dobutamine stress study, or a normal LVEF and evidence that valve obstruction is the most likely cause of symptoms.[26]

Plus – long-term infective endocarditis antibiotic prophylaxis

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Plus –

long-term infective endocarditis antibiotic prophylaxis

Treatment recommended for ALL patients in selected patient group

Antibiotic prophylaxis for the prevention of infective endocarditis should be considered in patients with prosthetic cardiac valves, including transcatheter-implanted prostheses and homografts, before dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa.[26]

Consider – long-term anticoagulation

Back

Consider –

long-term anticoagulation

Treatment recommended for SOME patients in selected patient group

Anticoagulation with a vitamin K antagonist is indicated in patients who have had aortic valve replacement using prosthetic mechanical valves.[26]

Direct oral anticoagulants (DOACs) are not recommended in patients requiring long-term anticoagulation for a mechanical valve regardless of coexisting atrial fibrillation.[26]

Anticoagulation is not required if bioprosthetic valves are used, except in the presence of atrial fibrillation, where anticoagulation is indicated.

Consider – medical therapy

Back

Consider –

medical therapy

Treatment recommended for SOME patients in selected patient group

Medical therapy for hypertension and hyperlipidemia is appropriate in patients with AS and hypertension and/or coronary artery disease.[26]

Statin therapy is indicated for primary and secondary prevention of atherosclerosis in all patients with calcific AS on the basis of standard risk scores.[26]

severe AS: age 65-80 years

1st line – surgical OR transcatheter aortic valve replacement

Back

1st line –

surgical OR transcatheter aortic valve replacement

The ACC/AHA guidelines recommend either surgery or transfemoral transcatheter aortic valve replacement (TAVR) for symptomatic patients with severe AS who are ages 65 to 80 years and have no contraindications to transfemoral TAVR, after shared decision-making based on the patient wishes, anatomic considerations, concomitant coronary artery disease and/or other valvular heart disease, comorbidities (e.g., frailty, dementia), and surgical risk.[26]

Plus – long-term infective endocarditis antibiotic prophylaxis

Back

Plus –

long-term infective endocarditis antibiotic prophylaxis

Treatment recommended for ALL patients in selected patient group

Consider – long-term anticoagulation

Back

Consider –

long-term anticoagulation

Treatment recommended for SOME patients in selected patient group

Anticoagulation with a vitamin K antagonist is indicated in patients who have had aortic valve replacement using prosthetic mechanical valves.[26]Direct oral anticoagulants (DOACs) are not recommended in patients requiring long-term anticoagulation for a mechanical valve regardless of coexisting atrial fibrillation.[26]

Anticoagulation is not required if bioprosthetic valves are used, except in the presence of atrial fibrillation, where anticoagulation is indicated.

Consider – medical therapy

Back

Consider –

medical therapy

Treatment recommended for SOME patients in selected patient group

Medical therapy for hypertension and hyperlipidemia is appropriate in patients with AS and hypertension and/or coronary artery disease.[26]

Statin therapy is indicated for primary and secondary prevention of atherosclerosis in all patients with calcific AS on the basis of standard risk scores.[26]

In patients who have undergone TAVR, renin-angiotensin system blocker therapy (ACE inhibitor or angiotensin receptor blocker) may be considered to reduce the long-term risk of all-cause mortality.[26]

severe AS: age >80 years or life expectancy <10 years or high/prohibitive risk

1st line – transcatheter aortic valve replacement

Back

1st line –

transcatheter aortic valve replacement

The ACC/AHA guidelines recommend transcatheter aortic valve replacement (TAVR) in preference to surgery in symptomatic patients with severe AS who are: ages >80 years, or for younger patients with a life expectancy <10 years and no contraindication to transfemoral TAVR; of any age and have a high or prohibitive surgical risk, if the predicted post-TAVR survival is >12 months with an acceptable quality of life.[26]

Surgical risk can be estimated using scoring systems such as the Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) and the EuroScore II.[46] Society of Thoracic Surgeons: risk calculator Opens in new window These models utilize a variety of risk factors to predict postoperative outcome after valve surgery. Mortality estimates are used in conjunction with assessments of frailty, major organ system compromise, and procedure-specific impediments to classify each patient’s overall surgical risk: low risk; intermediate risk; high risk; prohibitive risk.[26]

Plus – long-term infective endocarditis antibiotic prophylaxis

Back

Plus –

long-term infective endocarditis antibiotic prophylaxis

Treatment recommended for ALL patients in selected patient group

Consider – long-term anticoagulation

Back

Consider –

long-term anticoagulation

Treatment recommended for SOME patients in selected patient group

Anticoagulation is not required if bioprosthetic valves are used, except in the presence of atrial fibrillation, where anticoagulation is indicated.

Consider – medical therapy

Back

Consider –

medical therapy

Treatment recommended for SOME patients in selected patient group

Medical therapy for hypertension and hyperlipidemia is appropriate in patients with AS and hypertension and/or coronary artery disease.[26]

Statin therapy is indicated for primary and secondary prevention of atherosclerosis in all patients with calcific AS on the basis of standard risk scores.[26]

clinically stable: asymptomatic

severe AS: LVEF <50%

1st line – surgical OR transcatheter aortic valve replacement

Back

1st line –

surgical OR transcatheter aortic valve replacement

The ACC/AHA guidelines recommend:

- Surgical aortic valve replacement (SAVR) in asymptomatic patients with severe AS and an LVEF <50%, who are ages <65 years or have a life expectancy >20 years.[26]Studies have reported significant differences in survival, beginning as early as 3 years post-valve replacement, between those with preoperative LVEF >50% and patients with LVEF <50%.[77] Delaying surgery in these patients may lead to irreversible LV dysfunction and worsened survival.

- Either surgical or transfemoral transcatheter aortic valve replacement (TAVR) in asymptomatic patients with severe AS and an LVEF <50%, who are 65 to 80 years of age and have no contraindications to transfemoral TAVR, after shared decision-making based on the patient wishes, anatomic considerations, concomitant coronary artery disease and/or other valvular heart disease, comorbidities (e.g., frailty, dementia), and surgical risk.[26]

- TAVR in preference to SAVR in asymptomatic patients with severe AS and LVEF <50% who are of any age and have: a life expectancy <10 years and no contraindication to transfemoral TAVR; a high or prohibitive surgical risk, if the predicted post-TAVR survival is >12 months with an acceptable quality of life.[26]

Plus – long-term infective endocarditis antibiotic prophylaxis

Back

Plus –

long-term infective endocarditis antibiotic prophylaxis

Treatment recommended for ALL patients in selected patient group

Consider – long-term anticoagulation

Back

Consider –

long-term anticoagulation

Treatment recommended for SOME patients in selected patient group

Anticoagulation with a vitamin K antagonist is indicated in patients who have had aortic valve replacement using prosthetic mechanical valves.[26]

Direct oral anticoagulants (DOACs) are not recommended in patients requiring long-term anticoagulation for a mechanical valve regardless of coexisting atrial fibrillation.[26]

Anticoagulation is not required if bioprosthetic valves are used, except in the presence of atrial fibrillation, where anticoagulation is indicated.

Consider – medical therapy

Back

Consider –

medical therapy

Treatment recommended for SOME patients in selected patient group

Medical therapy for hypertension and hyperlipidemia is appropriate in patients with AS and hypertension and/or coronary artery disease.[26]

Statin therapy is indicated for primary and secondary prevention of atherosclerosis in all patients with calcific AS on the basis of standard risk scores.[26]

severe AS: abnormal exercise test, very severe AS, rapid progression, or elevated BNP

1st line – surgical aortic valve replacement

Back

1st line –

surgical aortic valve replacement

The ACC/AHA guidelines recommend surgical aortic valve replacement (SAVR) in asymptomatic patients with severe AS and low surgical risk who have: an abnormal exercise test (i.e., decreased exercise tolerance [normalized for age and sex] or a fall in systolic blood pressure of ≥10 mmHg from baseline to peak exercise); very severe AS; rapid progression; elevated serum B-type natriuretic peptide (BNP) levels.

Plus – long-term infective endocarditis antibiotic prophylaxis

Back

Plus –

long-term infective endocarditis antibiotic prophylaxis

Treatment recommended for ALL patients in selected patient group

Consider – long-term anticoagulation

Back

Consider –

long-term anticoagulation

Treatment recommended for SOME patients in selected patient group

Anticoagulation with a vitamin K antagonist is indicated in patients who have had aortic valve replacement using prosthetic mechanical valves.[26]

Direct oral anticoagulants (DOACs) are not recommended in patients requiring long-term anticoagulation for a mechanical valve regardless of coexisting atrial fibrillation.[26]

Anticoagulation is not required if bioprosthetic valves are used, except in the presence of atrial fibrillation, where anticoagulation is indicated.

Consider – medical therapy

Back

Consider –

medical therapy

Treatment recommended for SOME patients in selected patient group

Medical therapy for hypertension and hyperlipidemia is appropriate in patients with AS and hypertension and/or coronary artery disease.[26]

Statin therapy is indicated for primary and secondary prevention of atherosclerosis in all patients with calcific AS on the basis of standard risk scores.[26]

severe AS: normal LV systolic function with progressive decrease in LVEF <60%

1st line – consider surgical aortic valve replacement

Back

1st line –

consider surgical aortic valve replacement

Surgical aortic valve replacement (SAVR) may be considered in asymptomatic patients with severe AS and normal LV systolic function at rest and low surgical risk, when there is a progressive decrease in LVEF on at least three serial imaging studies to <60% without an alternative cause.[26]

Consider – long-term infective endocarditis antibiotic prophylaxis

Back

Consider –

long-term infective endocarditis antibiotic prophylaxis

Treatment recommended for SOME patients in selected patient group

Consider – long-term anticoagulation

Back

Consider –

long-term anticoagulation

Treatment recommended for SOME patients in selected patient group

Anticoagulation with a vitamin K antagonist is indicated in patients who have had aortic valve replacement using prosthetic mechanical valves.[26]

Direct oral anticoagulants (DOACs) are not recommended in patients requiring long-term anticoagulation for a mechanical valve regardless of coexisting atrial fibrillation.[26]

Anticoagulation is not required if bioprosthetic valves are used, except in the presence of atrial fibrillation, where anticoagulation is indicated.

Consider – medical therapy

Back

Consider –

medical therapy

Treatment recommended for SOME patients in selected patient group

Medical therapy for hypertension and hyperlipidemia is appropriate in patients with AS and hypertension and/or coronary artery disease.[26]

Statin therapy is indicated for primary and secondary prevention of atherosclerosis in all patients with calcific AS on the basis of standard risk scores.[26]

nonsevere AS: undergoing bypass, valve, or aortic surgery

1st line – consider concomitant prophylactic valve replacement

Back

1st line –

consider concomitant prophylactic valve replacement

When patients with moderately stenotic valves undergo cardiac surgery, the decision to replace the valve is less clear cut than when there is severe stenosis. The increased risk of adding aortic valve replacement to the planned surgery needs to be balanced against the future likelihood of AS progressing to a severe, symptomatic state.

The ACC/AHA guidelines advise that aortic valve replacement with either transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR) may be considered for asymptomatic patients with moderate AS who are undergoing other cardiac surgery.[26]

Consider – long-term infective endocarditis antibiotic prophylaxis

Back

Consider –

long-term infective endocarditis antibiotic prophylaxis

Treatment recommended for SOME patients in selected patient group

Consider – long-term anticoagulation

Back

Consider –

long-term anticoagulation

Treatment recommended for SOME patients in selected patient group

Anticoagulation with a vitamin K antagonist is indicated in patients who have had aortic valve replacement using prosthetic mechanical valves.[26]

Direct oral anticoagulants (DOACs) are not recommended in patients requiring long-term anticoagulation for a mechanical valve regardless of coexisting atrial fibrillation.[26]

Anticoagulation is not required if bioprosthetic valves are used, except in the presence of atrial fibrillation, where anticoagulation is indicated.

Consider – medical therapy

Back

Consider –

medical therapy

Treatment recommended for SOME patients in selected patient group

Medical therapy for hypertension and hyperlipidemia is appropriate in patients with AS and hypertension and/or coronary artery disease.[26]

Statin therapy is indicated for primary and secondary prevention of atherosclerosis in all patients with calcific AS on the basis of standard risk scores.[26]

nonsevere AS: not undergoing bypass, valve, or aortic surgery

1st line – medical therapy and follow-up

Back

1st line –

medical therapy and follow-up

Medical therapy for hypertension and hyperlipidemia is appropriate in patients with AS and hypertension and/or coronary artery disease.[26] Statin therapy is indicated for primary and secondary prevention of atherosclerosis in all patients with calcific AS on the basis of standard risk scores.[26]

Serial transthoracic echocardiograms are recommended every 3 to 5 years in asymptomatic patients with mild stenosis, and every 1 to 2 years in asymptomatic people with moderate stenosis.[26]

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Aortic stenosis

Treatment algorithm

clinically unstable

medical therapy or balloon valvuloplasty

clinically stable: symptomatic

surgical aortic valve replacement

long-term infective endocarditis antibiotic prophylaxis

long-term anticoagulation

medical therapy

surgical OR transcatheter aortic valve replacement

long-term infective endocarditis antibiotic prophylaxis

long-term anticoagulation

medical therapy

transcatheter aortic valve replacement

long-term infective endocarditis antibiotic prophylaxis

long-term anticoagulation

medical therapy

clinically stable: asymptomatic

surgical OR transcatheter aortic valve replacement

long-term infective endocarditis antibiotic prophylaxis

long-term anticoagulation

medical therapy

surgical aortic valve replacement

long-term infective endocarditis antibiotic prophylaxis

long-term anticoagulation

medical therapy

consider surgical aortic valve replacement

long-term infective endocarditis antibiotic prophylaxis

long-term anticoagulation

medical therapy

consider concomitant prophylactic valve replacement

long-term infective endocarditis antibiotic prophylaxis

long-term anticoagulation

medical therapy

medical therapy and follow-up