Asymptomatic Aortic Stenosis and Exercise Test

Euro Heart Survey on Valvular Heart Disease1 « The use of stress testing was low Essentially aimed at identifying coronary artery disease which it does poorly in the setting of valve disease Too seldom used in asymptomatic patients with valve disease This is particularly true for Aortic Stenosis despite the fact that the performance of the test is strongly advocated » Iung et al.ESC Survey on Valvular Heart Disease. Eur Heart J 2003; 24 : 1231-43

Exercise tests performed AS AR MS MR ET 6.7% 12.2% 7.4% 11.3% AS : 5.7% of asymptomatic patients : under-utilisation 3.2% of NYHA3 et 4 patients : ????? (1) Iung et al.ESC survey on valvular heart disease. Eur Heart J 2003; 24 : 1231-43

Comparison surgical indication/ guidelines2 20,7 % « overused » of intervention (2) Iung et al. Recommendations on the management of the asymptomatic patients with valvular heart disease. Eur Heart J 2002; 23 : 1253-66

How to Avoid Sudden Death in Asymptomatic Aortic Stenosis ? Post operative valve Sudden death surgical mortality relatedcomplication <1% per year (0,4%) 1% (5% after 75 years) 1-2 % per year

Mortality after Aortic Valve Replacement Rahimtoola. Circulation 2000; IV.24-33

But dont operate too late … Valve replacement No surgery (Symptomatic Aortic Stenosis) Scwartz E. Circulation 1982; 66 : 1105-10

Exercise test indications in AS Symptomatic patients : none Reduced Ejection Fraction : none Reduced EF in asymptomatic patients : ~ does not exist Reduced EF in symptomatic patients Surgical indication if mild EF reduction Surgical indication if contractile reserve in low output patients1 (Mean gdt < 30 mm Hg) (1)Monin . Circulation 2003; 108 : 319-324

Exercise test indications in AS(2) Identifying coronary heart disease : none Asymptomatic patients : Strongly recommended1,2 Gibbons ACC/AHA guideline update for exercise testing. Circulation 2002; 106 :1883-92 (2) Iung et al. Recommendations on the management of the asymptomatic patients with valvular heart disease. Eur Heart J 2002; 23 : 1253-66

First study : Feasibility : OTTO 1997 123 asymptomatic patients Followed 2.5 + 1.4 years End points : death or AVR Circulation 1997; 95 : 2262-70

Initial Values End point – (n = 67) End point + (n = 56) P 3.3 + 0.5 Peak Ao jet velocity 3.3 + 0.5 3.9 + 0.5 <0.001 Mean Ao gdt 25 ± 8 36 ± 12 Valve Area 1.53 ± 0.53 1.11 ± 0.34 Impossibility to perform ET 40 % 70 % =0.007 Exercise SBP change 29 ± 20 15 ± 17 Exercise Valve Area change 0.27 ± 0.36 0.05 ± 0.26

Multivariate Analysis Aortic jet velocity at baseline (p < 0.0001) Rate of change over time in jet velocity (p < 0.0001) Baseline functional status score (p = 0.002) Standardized questionnaire Validity in asymptomatic patients ?

Confirmation : Amato1 Selection : out of 853 diagnosed as having aortic valve stenosis : Inclusion if AS < 1 cm2 Asymptomatic Absence of coronary artery disease Exercise test interpretable Absence of LBB (1) Amato MC; Heart 2001; 86 : 381-86

Methods Exercise Test positivity criteria : ST > 2 mm (1mm in men, 2 mm in women, 3 mm for upsloping ST) AS symptoms Complex Ventricular Arrythmia SBP rise < 20 mm Hg End point : death + symptoms

Results Patients Positive exercise test : n = 44 (66%) 49.7 + 14.9 years; men 66% Aortic Valve Area : 0.61 + 0.17 cm2 Positive exercise test : n = 44 (66%) Follow up : 14.8 + 12 months

Valvular area Positive ET

Events : death or symptoms ET positive Symptom free survival : 19 % 4 sudden death (6%) ET negative Symptom free survival : 85 % (RR = 7.43 by multivariate analysis). Zero death Conclusion : Aortic valve replacement can be postponed in asymptomatic patients with negative ET Heart 2001; 86 : 381-6

Other studies Alborino1 Lancellotti2 N = 30 N = 63 Exercise echocardiography Alborino. J Heart Valve Dis 2002; 11 : 204-209 Lancellotti . AHA 2004; abstr n° 3279

Positivity criteria of exercise in ECG in patients with aortic stenosis1 Symptoms : Angina, dyspnea, near syncope Rise in SBP < 20 mmhg (or fall) Exercise tolerance < 80% of the normal target Down-sloping ST > 2mm Complex Ventricular arrythmia VT, more than 4 PVC in a row (1) Iung B et al. Recommendations on the management of the asymptomatic patients With valvular heart disease. Eur Heart J 2002; 23 : 1253-66

Recommendations for Aortic Valve Replacement in Asymptomatic Aortic Stenosis (<1cm2 ou 0.6 cm2/m2) Abnormal ET (IIa) LVEF < 50 % (IIa) LV Hypertrophy > 15 mm (IIb) Valve Area < 0.6 cm2 (IIb) VT (IIb) Prevention of sudden death in asymptomatic patients with none of the five findings above (III) Bonow R et al.ACC/AHA Guidelines for the management of patients with valvular heart disease. JACC 1998; 32(5) : 1486-1588

Aortic Stenosis < 1 cm2 Symptoms And normal or subnormal LVEF Low output Asymptomatic Dobutamine Echo Exercise Test AVR

Severe Aortic stenosis (<1 cm2 or 0.6 cm2/ m2) without symptoms Echocardiography Exercise test BNP ? Exercise Echocardiography ? Positive Negative : close monitoring Aortic Valve Replacement -Peak jet velocity > 4m/s and Progression of PV > 0.3m/s/year and rather severe calcifications -Ventricular arrythmia -> 15 mm Wall thickness