Asymptomatic Severe Aortic Stenosis in the Elderly: When to Intervene

This work studies the natural history of aortic stenosis and the optimal timing to intervene elderly patients with asymptomatic severe aortic stenosis.

This disease is increasingly misdiagnosed in the elderly population, and this goes hand in hand with enhanced therapeutic options.

Prior studies on the natural history of this disease were made on much younger populations (between 60 and 70) and it was these studies clinical guidelines were based on.

Deciding when to intervene elderly patients based on guidelines written for younger patients, could lead to serious mistakes. This is the first work to study the natural history of aortic stenosis in elderly patients. 

A total of 103 consecutive >70 patients (mean age 77±5 years) with asymptomatic severe aortic stenosis (peak systolic velocity 4.7±0.6 m/s) were followed up prospectively.

During follow up, there were 91 events, including aortic valve replacement indication in 82 patients, and cardiac death in 9 patients. Event free survival rate was:

• 73% at one year
• 43% at two years
• 23% at three years
• 16% at four years

Symptoms onset was severe (functional class ≥3) in 43% of the population.

Patients with peak systolic velocity ≥5 m/s presented:

• 21% event free survival rate at two years
• 4% event free survival rate at four years.

Patients with peak systolic velocity <5 m/s (p<0.001) presented:

• 57% event free survival rate at two years
• 23% event free survival rate at four years

Seventy one patients received aortic valve replacement and postop survival rate was 89% at one year and 77% at 3 years after procedure.

Conclusion

It might be difficult to detect mild symptoms in elderly patients with asymptomatic severe aortic stenosis, even when closely monitored.  We should expect a high events rate, and cardiac death at symptom onset is not infrequent.

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Because of this, elective aortic valve replacement should be considered particularly in patients with more than 5 m/s peak velocity and relatively low periprocedural risk.

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Original Title: Asymptomatic Severe Aortic Stenosis in the Elderly.

Reference: Robert Zilberszac et al. J Am Coll Cardiol Img 2017;10:43–50.

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