Aortic stenosis follow up

Resident Survival Guide

Aortic Stenosis Microchapters
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Usama Talib, BSc, MD [2]

Overview

Follow up is recommended for all patients with operated and unoperated aortic stenosis. Asymptomatic patients with aortic stenosis should undergo follow up since aortic stenosis is an ongoing disease that progresses with time. In fact, asymptomatic patients should undergo follow up every 1 year, 3 years and 5 years in case of severe, moderate and mild aortic stenosis respectively.

Follow-Up

Frequency of echocardiograms in asymptomatic patients with aortic stenosis with normal stroke volume:

• Progressive (stage B) with mild severity (V_max 2.0-2.9 m/s): every 3-5 years
• Progressive (stage B) with moderate severity (V_max 3.0-3.9 m/s): every 1-2 years
• Severe (stage C) (V_max>4 m/s): every 6-12 months

2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

The timing of periodic clinical assessment in asymptomatic patients with severe AS is dependent on comorbidities, patient-specific characteristics, and the severity of the AS (Table 4). Aortic velocity 4.0 m/s, which indicates severe AS, is associated with a rapid onset of symptoms and a 2-year event-free survival rate of only 30% to 50%. Periodic monitoring is required in patients with severe AS who are asymptomatic since the onset of symptoms is gradual and the patient may not be aware of them. The typical annual rate of advancement for moderate AS (aortic velocity 3.0-3.9 m/s) is a rise in velocity of 0.3 m/s, an increase in the mean pressure gradient of 7 mm Hg, and a decrease in valve area of 0.1 cm2. There is significant individual variation, with older individuals and patients with more severe leaflet calcification progressing more quickly. Within five years, 10% of patients with aortic sclerosis—defined as localized regions of valve calcification and leaflet thickening with an aortic velocity 2.0 m/s—progress to severe AS. Patients with BAV illness are also at risk for developing increasing valve stenosis, with AS being the most typical indication for BAV patient intervention (Section 5.1.1).

2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Diseases (DO NOT EDIT)

Diagnostic Testing - Routine Follow-Up

Class I

"1. Periodic monitoring with TTE is recommended in asymptomatic patients with known valvular heart disease at intervals depending on valve lesion, severity, ventricular size, and ventricular function. (Level of Evidence:C) "

2008 ACC/AHA Guidelines for the Management of Adults With Congenital Heart Disease (DO NOT EDIT)

Recommendations for Key Issues to Evaluate and Follow-Up (DO NOT EDIT)

Class I

"1. Lifelong cardiology follow-up is recommended for all patients with aortic valve disease (AS or AR). (Level of Evidence: A)"

"2. Serial imaging assessment of aortic root anatomy is recommended for all patients with BAV, regardless of severity. The frequency of imaging would depend on the size of the aorta at initial assessment: if less than 40 mm, it should be reimaged approximately every 2 years; if greater than or equal to 40 mm, it should be reimaged yearly or more often as progression of root dilation warrants or whenever there is a change in clinical symptoms or findings. (Level of Evidence: B)"

"3. Prepregnancy counseling is recommended for women with AS who are contemplating pregnancy. (Level of Evidence: B)"

"4. Patient referral to a pediatric cardiologist experienced in fetal echocardiography is indicated in the second trimester of pregnancy to search for cardiac defects in the fetus. (Level of Evidence: C)"

"5. Women with BAV and ascending aorta diameter greater than 4.5 cm should be counseled about the high risks of pregnancy. (Level of Evidence: C)"

"6. Patients with moderate to severe AS should be counseled against competitive athletics and strenuous isometric exercise. (Level of Evidence: B)"

"7. Echocardiographic screening for the presence of BAV is recommended for first-degree relatives of patients with BAV. (Level of Evidence: B)"