02 May

The Natural History and Rate of Progression of Aortic Stenosis: Severe aortic stenosis

A cohort of 51 asymptomatic patients with severe aortic stenosis were followed up by Kelly and coworkers for a mean of 17 months. A Doppler-derived peak systolic pressure gradient of ^50 mm Hg was used to define severe aortic stenosis. The aortic valve area was not calculated in this study. Twenty-one (41%) of the patients became symptomatic. Only two died of cardiac causes, but both had become symptomatic for at least 3 months prior to their deaths. The conclusion was, again, that patients be followed up until symptoms develop.

The conclusion that asymptomatic patients with acquired valvular aortic stenosis be followed up closely until symptoms develop was echoed by Pel-likka et al. They followed up 113 asymptomatic patients with significant aortic stenosis as determined by a Doppler-derived peak instantaneous systolic pressure gradient of ^64 mm Hg. The average mean gradient was 47 mm Hg. The mean duration of follow-up was 20 months. The death of three patients was ascribed to aortic stenosis (two, sudden death; one, congestive heart failure). In each case, the development of symptoms preceded death by at least 3 months. The actuarial probability of survival was 96%, 94%, and 90% at 6, 12, and 24 months, respectively. The survival did not differ from that predicted for age- and gender-matched control subjects.
Another review of 66 patients with moderate aortic stenosis again identified that symptoms predict adverse outcomes. Mortality was significantly greater (p<0.05) among symptomatic (New York Heart Association functional class III to IV) vs minimally symptomatic patients (23% vs 4%). Moderate aortic stenosis was defined as an aortic valve area of 0.7 to 1.2 cm2 derived by the formula of Hakki. The mean duration of follow-up was 35 months (maximum 7.2 years).
Despite the limitations of the studies, the consensus is that asymptomatic patients are at low risk for complications or mortality. However, following the onset of symptoms, the prognosis worsens dramatically. Surgical therapy should be considered as soon as the patient develops symptoms ascribed to aortic stenosis and if considered a viable option should be performed without delay.

Categories: Aortic Stenosis
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