Treatment decision in asymptomatic aortic valve stenosis: role of exercise testing

Abstract

Objective-To determine the prognostic value of exercise testing, valve area, and maximum transaortic pressure gradient in asymptomatic patients with aortic valve stenosis. Setting-The outpatient service of a tertiary referral centre for cardiology. Design-Prospective clinical study. Patients-66 consecutive patients with isolated severe aortic stenosis (aortic valve area < 1.0 cm 2 ) were selected over a 58 month period. Mean (SD) follow up was 14.77 (11.93) months. Interventions-At the initial visit Doppler echocardiography and exercise testing were performed to evaluate ST segment depression and the development of symptoms of aortic stenosis, ventricular arrhythmia, or inadequate rise of systolic blood pressure during exercise. Follow up clinical examinations were performed every three months thereafter to record the onset of symptoms. Main outcome measures-Sudden death or the development of symptoms. Results-Eight patients developed dizziness during exercise testing but made a rapid and spontaneous recovery. No other complications of exercise testing occurred. Survival curves, with or without the occurrence of end point events for the variables studied, showed significant diVerences for positive versus negative exercise testing (p = 0.0001) and aortic valve area < 0.7 cm 2 v > 0.7 cm 2 (p = 0.0021). There was no relation between the end points and transaortic gradient (p = 0.6882). In multivariate analysis, a hazard ratio of 7.43 was calculated for patients with a positive versus a negative exercise stress test. Although asymptomatic in daily life, 6% of the patients (4/66) experienced sudden death; all these had a positive exercise test and an aortic valve area of < 0.6 cm 2 . Conclusions-Exercise testing is safe and is of prognostic value in asymptomatic patients with aortic stenosis. (Heart 2001;86:381-386)

Prognostic Value of Exercise Tolerance Testing in Asymptomatic Chronic Nonischemic Mitral Regurgitation

“…Our data parallel investigations that have documented the prognostic value of exercise duration in AR (6) and coronary artery disease (5) and its correlation with symptoms in patients with mixed MR and AR (24). They also suggest that exercise tolerance from ETT can be useful in detecting unreported symptoms from MR, as is true, and prognostically useful, among patients with aortic stenosis (25). Since patients may minimize activity without recognizing the cause, observation of exertional dyspnea by the clinician during ETT (found in almost a quarter of our patients during index testing) may be useful in defining subsequent management.…”

Sténose aortique sévère asymptomatique à fraction d’éjection ventriculaire gauche préservée. Évaluation à l’effort : quels résultats et quelles décisions ?

“…Il est démontré que 20 % à 30 % des patients porteurs d'une SA sévère asymptomatique présentent un test d'effort anormal [5,6].…”

“…La valeur prédictive positive de symptômes induits par l'exercice pour la survenue de symptômes spontanés dans les 12 mois était médiocre (57 %) dans le travail de Das et al, mais apparaissait meilleure (79 %) chez les patients jeunes physiquement actifs (< 70 ans) [12]. Bien que non spécifique, la survenue des autres symptômes (vertiges, angor, ou syncope), en particulier chez les patients âgés de moins de 70 ans entretenant une activité physique [12], prédit le développement rapide des symptômes dans la vie quotidienne dans l'année qui suit [5,6]. Un RVAo est alors recommandé (classe I C) quand le test à l'effort est positif [1].…”

“…La survenue de symptômes limitant l'exercice (lipothymie, dyspnée à des charges faibles lors du test d'effort, angine de poitrine ou syncope) bien que non spécifiques, prédit la progression rapide des symptômes dans la vie quotidienne, la mort d'origine cardiaque (y compris la mort subite) et la nécessité d'un RVAo [5,6]. La prise en charge des patients présentant une SA sévère asymptomatique est par contre controversée.…”

Outcomes in Asymptomatic Severe Aortic Stenosis With Preserved Ejection Fraction Undergoing Rest and Treadmill Stress Echocardiography

“…In addition, exercise‐induced drop in systolic blood pressure is a Class IIa indication for surgery1, 2 However, these recommendations are based upon multiple small reports with heterogeneous end points3, 9, 10, 11, 12, 13, 14, 15 In a recent study, we have demonstrated that in asymptomatic patients with severe AS and preserved left ventricular ejection fraction (LVEF), only 50% achieved 100% of age‐sex predicted exercise capacity; with exercise stress testing providing significant reclassification of longer‐term mortality risk16 In the past decade, novel echo parameters including reduced left ventricular global longitudinal strain (LV‐GLS)17, 18, 19 and valvuloarterial impedance (Zva)17, 19, 20 have also been associated with worse prognosis in patients with asymptomatic severe AS. However, no study has systematically evaluated the incremental prognostic impact of resting Zva and LV‐GLS on data obtained from exercise stress testing in patients with asymptomatic severe AS and preserved LVEF.…”