Content 9



Mortality Reduction With Early Surgery For Severe Aortic Stenosis

Asymptomatic patients do better than with wait-and-see policy




First Appropriate Use Criteria Issued for Severe Aortic Stenosis

  • Posted: 10/17/2017
  • Author: 

    Nicole Lou,Reporter, MedPage Today/

Multi-society guide OKs intervention for most symptomatic cases

Cardiology professional societies combined forces to issue the first appropriate use criteria (AUC) for the treatment of patients with severe aortic stenosis.

The document outlining 95 common clinical scenarios and the treatments deemed “rarely appropriate,” “may be appropriate,” or “appropriate” appeared online in the Journal of American College of Cardiology and flagship journals of certain other of the 11 collaborating societies.

Treatments addressed included transcatheter aortic valve replacement (TAVR), surgical aortic valve replacement (SAVR), and balloon aortic valvuloplasty as a bridge to valve replacement or to palliative care; but the AUC also considered when no intervention is best.

Intervention was deemed generally appropriate in symptomatic patients, though in “scenarios in which expected survival is less than one year and overall health status is influenced more by comorbidities than aortic stenosis, a less aggressive option (medical management) is considered Appropriate.”

“In scenarios in which the patient has reduced ejection fraction, intervention is generally considered ‘appropriate,’ with the decision for TAVR or SAVR based predominantly on surgical risk,” the AUC stated, “the only exceptions being situations in which stress test results suggest that the stenosis is pseudosevere rather than severe or in which LV systolic function is profoundly impaired without contractile reserve. In these patients, medical management is considered ‘appropriate.’

“In the asymptomatic patient, a positive stress test effectively identifies the patient as symptomatic, with intervention again considered ‘appropriate’ regardless of surgical risk. In asymptomatic patients with findings suggesting likelihood of symptom onset but not sudden death, intervention is rated ‘appropriate,’ whereas medical management is considered ‘may be appropriate.’”

Writing group chair Robert Bonow, MD, of Northwestern University’s Feinberg School of Medicine in Chicago, and colleagues emphasized that the scenarios presented were at the “extremes of comorbidity as black and white examples” and acknowledged that real-life patients usually “present in shades of gray.”

“There needs to be flexibility in interpreting the nuances of many of these scenarios, just as there needs to be sound clinical judgment in making treatment decisions given the increasing complexity of patients with aortic stenosis,” the authors emphasized. “The writing group recognizes that this field is evolving very rapidly, and hence this document will need to be updated in a timely manner in order to reflect advances in technology and clinical outcomes.”

Societies that signed on to the AUC were the American College of Cardiology, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, European Association for Cardio-Thoracic Surgery, Heart Valve Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons.



Bonow disclosed representing the American College of Cardiology, conducting personal research at Harvard Clinical Research Institute, and having institutional ties to Gilead Sciences.


Journal of the American College of Cardiology

Bonow RO, et al “ACC/AATS/AHA/ASE/EACTS/ HVS/SCA/SCAI/SCCT/SCMR/STS 2017 appropriate use criteria for the treatment of patients with severe aortic stenosis” J Am Coll Cardio 2017; DOI: 10.1016/j.jacc.2017.09.018.


Content 4

E. Based on the way this patient presented, what is his life expectancy if left untreated?

Once symptoms occur in aortic stenosis, without treatment the prognosis is poor. Life expectancy is 2 years if aortic stenosis causes angina and 3 years if aortic stenosis causes syncope.


A 72-year-old man with a history of hyperlipidemia presents with a syncopal episode and is noted to have a systolic murmur on exam.

  • What valvular abnormality is concerning in the presentation of syncope?

    — Aortic stenosis (AS)

  • What are the typical characteristics of the murmur of AS? (Listen to Audio)

    — Timing: Mid-systolic; Shape: crescendo-decrescendo; Location of maximal intensity: Right 2nd intercostal space (base of heart);Radiation: Upward to the carotid arteries; Pitch: Low; Quality: Rough

    (Listen to Audio)


A 59-year-old man is brought to the emergency department by ambulance after experiencing a syncopal episode. He states that he was running in the park when he suddenly lost consciousness. He denies any symptoms preceding the event, and he had no deficits or symptoms upon arousing. On review of systems, he does say that he has had substernal chest pressure associated with exercise for the past several weeks. Each episode was relieved with rest. He denies shortness of breath, dyspnea on exertion, orthopnea, and paroxysmal nocturnal dyspnea. His medical history is notable for multiple episodes of pharyngitis as a child. He is otherwise well. He has no significant family history. He was born in Mexico and moved to the United States at age 10 years. He does not smoke, drink alcohol, or use drugs. On examination, his blood pressure is 110/90 mm Hg, heart rate 95 bpm, respiratory rate 15/min, and oxygen saturation 98%. Neck examination reveals both pulsus parvus and pulsus tardus. Cardiac examination reveals a laterally displaced and sustained apical impulse. He has a grade 3/6 midsystolic murmur, loudest at the base of the heart, radiating to the neck, and a grade 1/6 high-pitched, blowing, early diastolic murmur along the left sternal border. An S4 is audible. Lungs are clear to auscultation. Abdominal examination is benign. He has no lower extremity edema. Aortic stenosis is suspected.