Contemporary Workup and Management of Asymptomatic Patients with Severe Aortic Stenosis

Purpose of reviewAppropriate management of asymptomatic patients with severe aortic stenosis (AS) is increasingly debated given recent improvements in options for aortic valve replacement (AVR). The goal of this review is to provide an updated approach to evaluation and management of patients with asymptomatic severe AS and to discuss the rationale for early AVR.Recent findingsRegistry data, retrospective studies, and one small randomized controlled clinical trial suggest a mortality benefit to AVR before symptom onset, although larger randomized trials are needed given potential biases of observational data. Other promising approaches to risk stratification of asymptomatic adults with severe AS include cardiac biomarkers (such as serum B-type natriuretic peptide levels), left ventricular global longitudinal strain, and myocardial fibrosis detected on cardiac magnetic resonance imaging.SummaryRoutine close clinical follow-up, periodic imaging, patient education, and shared decision-making are essential in caring for asymptomatic patients with severe AS but there is not yet enough evidence to support early AVR in most patients. Ongoing clinical trials and evaluation of biomarkers will illuminate whether intervention before symptom onset will improve the length or quality of life in adults with severe AS.