What are the guideline sources, guidelines and references for Aortic stenosis ?
Guideline sources The following summarized guidelines for the evaluation and management of aortic stenosis (AS) are prepared by our editorial team based on guidelines from the American Heart Association (AHA/ACC 2021) and the European Society of Cardiology (ESC/EACTS 2021). 1 2 3 3 3 3 4 5 6 7 Definition AS is a chronic fibrocalcific disease that results in narrowing of the aortic valve. 3 Epidemiology AS is caused by the interplay of structural (e.g. bicuspid aortic valve), hereditary (e.g. genetic polymorphisms of lipoprotein A gene), and acquired (e.g. progressive age-related calcification, rheumatic valve disease) factors. Turbulent flow through a stenotic aortic valve causes endothelial damage, with subsequent sub-endothelial inflammation and accumulation of oxidized lipoproteins, and leads to deposition of calcium on the valve with progression of stenosis. 3 6 Pathophysiology https://web.pathway.md/diseases/recPKP0FKP30zAZyO 1/8 6/23/23, 2:40 AM Aortic stenosis Pathway Pathophysiology The prevalence of AS in the United States is estimated at 400 persons per 100,000 population. The incidence of AS-related admissions in the United States is estimated at 9.5-26 cases per 100,000 patient-years. 4 5 Disease course AS results in obstruction to the ejection of blood the left ventricle, with resultant signs and symptoms of left-sided HF. 3 Prognosis and risk of recurrence The overall survival of elderly patients with severe AS is 3 years from the onset of symptoms. In patients with severe, symptomatic AS who are at prohibitive risk for aortic valve replacement, the 1- year and 5-year mortality rates are 50% and >90%, respectively. 3 7 Calculator Calculator Calculator Cardiac Anesthesia Risk Evaluati NYHA functional classification f Revised C Guidelines 1. Diagnostic investigations Transthoracic echocardiogram: Obtain TTE for accurate diagnosis of the cause of AS, assessment of hemodynamic severity, measurement of LV size and systolic function, and determination of prognosis and timing of valve intervention in patients with signs or symptoms of AS. A Consider calculating the ratio of the outflow tract to aortic velocity to further define severity in patients with suspected low-flow, low-gradient severe AS with normal or reduced LV ejection fraction (stages D2-D3). C Dobutamine stress testing: consider obtaining low-dose dobutamine stress testing with echocardiographic or invasive hemodynamic measurements to further define severity and assess contractile reserve in patients with suspected low-flow, low-gradient severe AS with reduced LV ejection fraction (stage D2). C Exercise stress testing: Consider obtaining exercise testing to assess physiological changes with exercise and to confirm the absence of symptoms in asymptomatic patients with severe AS (stage C1). C Do not obtain exercise testing in symptomatic patients with severe AS (stage D1, aortic velocity 4.0 m/s or mean pressure gradient 40 mmHg) because of the risk of severe hemodynamic compromise. D https://web.pathway.md/diseases/recPKP0FKP30zAZyO 2/8 6/23/23, 2:40 AM Aortic stenosis Pathway Cardiac computed tomography: consider obtaining CT for the measurement of aortic valve calcium score to further define severity in patients with suspected low-flow, low-gradient severe AS with normal or reduced LV ejection fraction (stages D2 and D3). C 2. Diagnostic procedures Coronary angiography: Obtain coronary angiography before valve surgery in patients with severe VHD and any of the following: history of CVD suspected myocardial ischemia LV systolic dysfunction age > 40 for males postmenopause 1 cardiovascular risk factors. B Consider obtaining coronary CT angiography as an alternative to coronary angiography before valve surgery in patients with severe VHD and low probability of coronary artery disease. C 3. Medical management Antihypertensive therapy: ensure optimization of BP control before measurement of AS severity by TTE, TEE, cardiac catheterization, or cardiac magnetic resonance in patients with suspected low-flow, low-gradient severe AS with normal LV ejection fraction (stage D3). B Show 2 more Statin therapy: Initiate statins for primary and secondary prevention of atherosclerosis on the basis of standard risk scores in all patients with calcific AS. A Do not use statins for the prevention of hemodynamic progression of AS in patients with calcific AS (stages B and C). D Landmark trials: SALTIRE In patients with calcific aortic stenosis, treatment with atorvastatin, as compared with placebo, did not reduce the progression of aortic stenosis, as assessed by the change in aortic-jet velocity and aortic-valve calcium score. Serum LDL cholesterol decreased significantly in the atorvastatin group. Cowell SJ et al. N Engl J Med. 2005 Jun 9. https://web.pathway.md/diseases/recPKP0FKP30zAZyO 3/8 6/23/23, 2:40 AM Aortic stenosis Pathway 4. Therapeutic procedures Percutaneous aortic balloon dilation: As per AHA 2021 guidelines, consider performing percutaneous aortic balloon dilation as a bridge to SAVR or TAVI in critically ill patients with severe AS. C As per ESC 2021 guidelines, consider performing balloon aortic valvotomy as a bridge to SAVR or TAVI in hemodynamically unstable patients and (if feasible) in patients with severe AS requiring urgent high-risk non-cardiac surgery. C 5. Surgical interventions Aortic valve replacement (risk assessment): calculate individual risks for specific surgical and/or transcatheter procedures, using on-line tools when available, in patients with valvular heard disease when an intervention is contemplated, and discuss those risks before the procedure as a part of a shared decision-making process. B Aortic valve replacement, indications: As per AHA/ACC 2021 guidelines, perform aortic valve replacement in adult patients with severe high-gradient AS (stag D1) and symptoms of exertional dyspnea, HF, angina, syncope, or presyncope by history or on exercise testing. A Show 10 more As per EACTS/ESC 2021 guidelines, perform intervention in symptomatic patients with severe, high-gradient AS (mean gradient 40 mmHg, peak velocity 4.0 m/s, and valve area 1.0 cm (or 0.6 cm /m ). B Show 9 more Aortic valve replacement, choice of approach: As per AHA/ACC 2021 guidelines, perform SAVR in symptomatic and asymptomatic patients with severe AS and any indication for aortic valve replacement aged < 65 years or having a life expectancy > 20 years. A Show 6 more As per EACTS/ESC 2021 guidelines, perform aortic valve interventions in heart valve centers declaring their local expertise and outcomes data, having active interventional cardiology and cardiac surgical programs on site, and a structured collaborative heart team approach. B Show 5 more Landmark trials: PARTNER 2 In intermediate risk patients with severe aortic stenosis, TAVR was noninferior to surgery with respect to death from all causes or disabling stroke at 2 years. Leon MB et al. N Engl J Med. 2016 Apr 28. https://web.pathway.md/diseases/recPKP0FKP30zAZyO 4/8 6/23/23, 2:40 AM Aortic stenosis Pathway Aortic valve replacement (choice of valves): choose a prosthetic valve based on a shared decision-making process accounting for the patient's values and preferences and including discussion of the indications for and risks of anticoagulant therapy and the potential need for and risks associated with valve reintervention in patients with an indication for aortic valve replacement. B Show 5 more 6. Specific circumstances Pregnant patients: consider performing valve intervention before pregnancy in asymptomatic female patients with severe AS (aortic velocity 4.0 m/s or mean pressure gradient 40 mmHg, stage C) considering pregnancy. C Show 2 more Patients with atrial fibrillation: As per AHA 2021 guidelines, initiate a non-vitamin K OAC as an alternative to vitamin K antagonists in patients with AF and native valve heart disease or in patients received a bioprosthetic valve > 3 months ago, based on the patient's CHA2DS2-VASc score. A Show 2 more As per ESC 2021 guidelines, initiate direct OACs over vitamin K antagonists for stroke prevention in patients with AS and AF eligible for oral anticoagulation. A Show 2 more Patients with coronary artery disease: As per AHA 2021 guidelines, consider performing SAVR and CABG over TAVI and PCI in patients with significant AS and coronary artery disease (luminal reduction > 70% diameter, fractional flow reserve < 0.8, instantaneous wave-free ratio < 0.89) consisting of complex bifurcation left main and/or multivessel coronary artery disease with a SYNTAX score > 33. C As per ESC 2021 guidelines, perform CABGing in patients with a primary indication for aortic valve surgery and coronary artery diameter stenosis 70%. B Show 2 more Patients undergoing cardiac surgery for other indications: As per AHA 2021 guidelines: Consider performing aortic valve replacement in patients with moderate AS (stage B) undergoing cardiac surgery for other indications. C Perform aortic valve replacement in asymptomatic patients with severe AS (stage C1) undergoing cardiac surgery for other indications. B As per ESC 2021 guidelines: Perform SAVR in patients with severe AS undergoing CABGing or surgical intervention on the ascending aorta or another valve. B Consider performing SAVR in patients with moderate AS undergoing CABGing or surgical intervention on the ascending aorta or another valve after heart team discussion. C https://web.pathway.md/diseases/recPKP0FKP30zAZyO 5/8 6/23/23, 2:40 AM Aortic stenosis Pathway Patients undergoing non-cardiac surgery: obtain preoperative echocardiography in patients with clinically suspected moderate or greater degrees of valvular stenosis undergoing non-cardiac surgery. B Show 2 more 7. Preventative measures Prevention of infective endocarditis: Consider administering antibiotic prophylaxis before dental procedures (involving manipulation of gingival tissue, manipulation of the periapical region of teeth, or perforation of the oral mucosa) in patients with VHD having any of the following: prosthetic cardiac valves, including transcatheter-implanted prostheses and homografts prosthetic material used for cardiac valve repair, such as annuloplasty rings, chords, or clips previous infective endocarditis unrepaired cyanotic congenital heart disease or repaired congenital heart disease, with residual shunts or valvular regurgitation at the site of or adjacent to the site of a prosthetic patch or prosthetic device cardiac transplant with valve regurgitation attributable to a structurally abnormal valve. C Do not administer antibiotic prophylaxis for non-dental procedures (such as TEE, EGD, colonoscopy, or cystoscopy) in the absence of active infection in patients with VHD at high risk of infective endocarditis. D Secondary prevention of rheumatic fever: administer secondary prevention of rheumatic fever in patients with rheumatic heart disease. B 8. Follow-up and surveillance Indications for referral: Evaluate patients with severe VHD by a multidisciplinary heart valve team when intervention is considered. B Consider consulting with or referring to a primary or comprehensive heart valve center when discussing treatment options for: asymptomatic patients with severe VHD patients likely to benefit from valve repair versus valve replacement patients with multiple comorbidities considered for valve intervention. C Post-intervention serial imaging: obtain a baseline postprocedural TTE in asymptomatic patients with any type of valve intervention followed by periodic monitoring with TTE, depending on type of intervention, length of time after intervention, ventricular function, and concurrent cardiac conditions. B https://web.pathway.md/diseases/recPKP0FKP30zAZyO 6/8 6/23/23, 2:40 AM Aortic stenosis Pathway Post-intervention palliative care: offer palliative care after shared decision-making, including discussion of patient preferences and values, in symptomatic patients with severe AS if predicted post-TAVI or post-SAVR survival is < 12 months or if minimal improvement in quality of life is expected. B Likelihood Ratios Pertinent positives The following findings increase the probability of aortic stenosis in adults. -1 Finding LR+ Value Delay in carotid pulse upstroke 9.2 (3.4-24) Presence of systolic murmur radiating to right carotid 8.1 (4-16) Decreased second heart sound 7.5 (3.2-17) Presence of systolic murmur over right clavicle 3.0 (2-4.1) Show 2 more Pertinent negatives The following findings decrease the probability of aortic stenosis in adults. -1 Finding LR- Value Absence of systolic heart murmur 0 Absence of systolic murmur over right clavicle 0.10 (0.02-0.44) Absence of systolic murmur radiating to right carotid 0.29 (0.12-0.57) second heart sound not decreased 0.50 (0.27-0.76) Show 2 more References 1. Catherine M Otto, Rick A Nishimura, Robert O Bonow et al. 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. J Thorac Cardiovasc Surg. 2021 Aug;162 2):e183-e353. Open 2. Alec Vahanian, Friedhelm Beyersdorf, Fabien Praz et al. 2021 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J. 2021 Aug 28;ehab395. Open 3. Carita P, Coppola G, Novo G et al. Aortic stenosis: insights on pathogenesis and clinical implications. J Geriatr Cardiol. 2016 Sep;13 6 489 98. Open 4. Nkomo VT, Gardin JM, Skelton TN et al. Burden of valvular heart diseases: a population-based study. Lancet. 2006 Sep 16;368 9540 1005 11. Open https://web.pathway.md/diseases/recPKP0FKP30zAZyO 7/8 6/23/23, 2:40 AM Aortic stenosis Pathway 5. Alqahtani F, Aljohani S, Amin AH et al. Effect of Race on the Incidence of Aortic Stenosis and Outcomes of Aortic Valve Replacement in the United States. Mayo Clin Proc. 2018 May;93 5 607 617. Open 6. Thaden JJ, Nkomo VT, Enriquez-Sarano M. The global burden of aortic stenosis. Prog Cardiovasc Dis. 2014 May-Jun;56 6 565 71. Open 7. Bakaeen FG, Rosengart TK, Carabello BA. Aortic Stenosis. Ann Intern Med. 2017 Jan 3;166 1 ITC1 ITC16. Open 8. Nishimura RA, Otto CM, Bonow RO et al. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014 Jun 10;129 23 2440 92. Open 9. Nishimura RA, Otto CM, Bonow RO et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014 Jun 10;63 22):e57 185. Open 10. Nishimura RA, Otto CM, Bonow RO et al. 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2017 Jun 20;135 25):e1159-e1195. Open 11. Baumgartner H, Falk V, Bax JJ et al. 2017 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J. 2017 Sep 21;38 36 2739 2791. Open 12. Alec Vahanian, Friedhelm Beyersdorf, Fabien Praz et al. 2021 ESC/EACTS Guidelines for the management of valvular heart disease: Developed by the Task Force for the management of valvular heart disease of the European Society of Cardiology ESC and the European Association for Cardio-Thoracic Surgery EACTS . Eur Heart J. 2021;ehab395. Open 13. Edward Etchells, MD, MSc et al. Does This Patient Have an Abnormal Systolic Murmur?. JAMA. 1997;277 7 564 571. Open https://web.pathway.md/diseases/recPKP0FKP30zAZyO 8/8