Managing Patients With Moderate Aortic Stenosis - JIMG June 2023-Article: Managing Patients With Moderate Aortic Stenosis

Article: Managing Patients With Moderate Aortic Stenosis - JIMG June 2023

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This state-of-the-art review discusses the management of patients with moderate aortic stenosis (AS), exploring its diagnosis, progression, risk stratification, and potential treatments. Moderate AS has been shown to be associated with a higher risk of cardiovascular events and mortality, but the root causes of these risks—whether due to comorbidities or the AS itself—remain not well understood.<br /><br />The diagnosis of moderate AS is often complicated by discordant grading between aortic valve area (AVA) and pressure gradients. Accurate diagnosis is crucial, as traditional echocardiographic evaluation focused solely on the aortic valve may miss the broader picture where left ventricular (LV) involvement is significant. An algorithm is provided to help correctly diagnose moderate AS, and multimodality imaging including echocardiography, cardiac computed tomography (CT), and cardiac magnetic resonance (CMR) is recommended to better understand the impact of the disease on LV function.<br /><br />In terms of management, the review highlights the lack of specific guideline-directed treatments for moderate AS and emphasizes the need for careful clinical surveillance. Current guidelines suggest considering aortic valve replacement (AVR) mainly if the patient requires coronary surgery for another indication. However, recent observational studies suggest that some patients with moderate AS might benefit from earlier intervention, particularly those with comorbidities or signs of cardiac remodeling. Trials like TAVR UNLOAD, which investigates transcatheter aortic valve replacement (TAVR) in patients with moderate AS and heart failure with reduced ejection fraction (HFrEF), are currently underway to explore these benefits more clearly.<br /><br />Practical tools include the use of dobutamine stress echocardiography (DSE) and CT calcium scoring to better stratify the risk in patients with discordant grading. Biomarkers like N-terminal pro–B-type natriuretic peptide (NT-proBNP) and high-sensitivity cardiac troponin I are also considered useful in predicting poor outcomes and may guide management decisions in future clinical practice. Ongoing research aims to detail the mechanistic pathways and clinical benefits of early AVR for selected patients with moderate AS, hoping to pave the way for more tailored interventions.

Keywords

moderate aortic stenosis

cardiovascular events

diagnosis

risk stratification

aortic valve replacement

multimodality imaging

left ventricular function

biomarkers

TAVR

clinical surveillance