Watchful waiting in aortic stenosis: are we ready for individualizing the risk assessment?

This editorial refers to ‘A clinical risk score of myocardial fibrosis predicts adverse outcomes in aortic stenosis’[†][1], by C.W. Chin et al ., on page 713. With the ageing of the population and increased use of echocardiography, aortic stenosis (AS) has become one of the most common valvulopathies encountered in the general population1. Current guidelines2,3 advocate aortic valve replacement (AVR) for severe AS patients in the presence of either: (i) classical symptoms (angina, syncope, or exertional dyspnoea) often difficult to ascertain in these patients with several co-morbidities; and/or (ii) left ventricular (LV) systolic dysfunction (i.e. LV ejection fraction <50%) which could be permanent. While for symptomatic patients with severe AS the decision to treat is relatively simple, the timing for prophylactic intervention in an asymptomatic patient with preserved LV systolic function remains controversial and a matter of continuous debate.4,5 Should we then focus on the asymptomatic patients? For these patients, the two main concerns are the small risk of sudden cardiac death (∼1%/year) and the potential development of subclinical LV dysfunction. The current guidelines emphasize the role of objective assessment of functional capacity and symptomatic status with supervised exercise testing, which, although important, might not be feasible in some patients. In the absence of unmasked symptoms and/or markers of increased risk such as hypotension and/or failure of blood pressure to increase with exercise, the approach of watchful waiting with close surveillance for symptoms development seems reasonable. However, there is a marked heterogeneity, with subsets of patients … [1]: #fn-2