Asymptomatic Aortic Stenosis and Exercise Test

Euro Heart Survey on Valvular Heart Disease1

« The use of stress testing was low

• Essentially aimed at identifying coronary artery disease which it does poorly in the setting of valve disease

• Too seldom used in asymptomatic patients with valve disease •This is particularly true for Aortic Stenosis despite the fact that the performance of the test is strongly advocated »

Iung et al.ESC Survey on Valvular Heart Disease. Eur Heart J 2003; 24 : 1231-43

Exercise tests performed

(1) Iung et al.ESC survey on valvular heart disease. Eur Heart J 2003; 24 : 1231-43

ASAS AR MS MR

AS : 5.7% of asymptomatic patients : under-utilisationAS : 5.7% of asymptomatic patients : under-utilisation 3.2% of NYHA3.2% of NYHA3 et 4 3 et 4 patientspatients : ?????: ?????

ET 6.7%6.7% 12.2% 7.4% 11.3%

Comparison surgical indication/ guidelines2

20,7 % « overused » of intervention

(2) Iung et al. Recommendations on the management of the asymptomatic patients with valvular heart disease.

Eur Heart J 2002; 23 : 1253-66

How to Avoid Sudden Death in Asymptomatic Aortic Stenosis ?

Post operative valve Sudden death surgical mortality relatedcomplication

<1% per year(0,4%)

1%(5% after 75 years)

1-2 % per year

Mortality after Aortic Valve Replacement

Rahimtoola. Circulation 2000; IV.24-33

But dont operate too late …

(Symptomatic Aortic Stenosis)Scwartz E. Circulation 1982; 66 : 1105-10

Valve replacement

No surgery

Exercise test indications in AS

• Symptomatic patients : none

• Reduced Ejection Fraction : none– Reduced EF in asymptomatic patients : ~ does

not exist– Reduced EF in symptomatic patients

• Surgical indication if mild EF reduction• Surgical indication if contractile reserve in low

output patients1 (Mean gdt < 30 mm Hg)

(1)Monin . Circulation 2003; 108 : 319-324

Exercise test indications in AS(2)

• Identifying coronary heart disease : none

• Asymptomatic patients :– Strongly recommended1,2

(1) Gibbons ACC/AHA guideline update for exercise testing. Circulation 2002; 106 :1883-92(2) Iung et al. Recommendations on the management of the asymptomatic patients with valvular heart disease. Eur Heart J 2002; 23 : 1253-66

First study : Feasibility :OTTO 1997

Circulation 1997; 95 : 2262-70

•123 asymptomatic patients

•Followed 2.5 + 1.4 years

•End points : death or AVR

Initial Values

End point –

(n = 67)

End point +

(n = 56)

P

Peak Ao jet velocity

3.3 + 0.5 3.9 + 0.5 <0.001

Mean Ao gdt 25 ± 8 36 ± 12 <0.001

Valve Area 1.53 ± 0.53 1.11 ± 0.34 <0.001

Impossibility to perform ET

40 % 70 % =0.007

Exercise SBP change

29 ± 20 15 ± 17 <0.001

Exercise Valve Area change

0.27 ± 0.36 0.05 ± 0.26 <0.001

Multivariate Analysis

• Aortic jet velocity at baseline (p < 0.0001)

• Rate of change over time in jet velocity (p < 0.0001)

• Baseline functional status score (p = 0.002)– Standardized questionnaire– Validity in asymptomatic patients ?

Confirmation : Amato1

• Selection : out of 853 diagnosed as having aortic valve stenosis :

• Inclusion if– AS < 1 cm2

– Asymptomatic– Absence of coronary artery disease– Exercise test interpretable

• Absence of LBB

(1) Amato MC; Heart 2001; 86 : 381-86

Methods

• Exercise Test positivity criteria :– ST > 2 mm (1mm in men, 2 mm in women, 3

mm for upsloping ST)– AS symptoms– Complex Ventricular Arrythmia– SBP rise < 20 mm Hg

• End point : death + symptoms

Results

• Patients • 49.7 + 14.9 years; men 66%

• Aortic Valve Area : 0.61 + 0.17 cm2

• Positive exercise test : n = 44 (66%)

• Follow up : 14.8 + 12 months

Valvular area

Positive ET

• Events : death or symptoms– ET positive

• Symptom free survival : 19 %• 4 sudden death (6%)

– ET negative• Symptom free survival : 85 % (RR = 7.43 by

multivariate analysis). • Zero death

Heart 2001; 86 : 381-6

Conclusion : Aortic valve replacement can be postponed

in asymptomatic patients with negative ET

Other studies

• Alborino1

• N = 30

• Lancellotti2

• N = 63

• Exercise echocardiography

(1) Alborino. J Heart Valve Dis 2002; 11 : 204-209(2) Lancellotti . AHA 2004; abstr n° 3279

Positivity criteria of exercise in ECG in patients with aortic stenosis1

• Symptoms : • Angina, dyspnea, near syncope

• Rise in SBP < 20 mmhg (or fall)• Exercise tolerance < 80% of the normal

target• Down-sloping ST > 2mm• Complex Ventricular arrythmia

• VT, more than 4 PVC in a row

(1) Iung B et al. Recommendations on the management of the asymptomatic patientsWith valvular heart disease. Eur Heart J 2002; 23 : 1253-66

Recommendations for Aortic Valve Replacement in Asymptomatic Aortic

Stenosis (<1cm2 ou 0.6 cm2/m2)

• Abnormal ET (IIa)• LVEF < 50 % (IIa)• LV Hypertrophy > 15 mm (IIb)• Valve Area < 0.6 cm2 (IIb)• VT (IIb)

Bonow R et al.ACC/AHA Guidelines for the management of patients with valvular heart disease. JACC 1998; 32(5) : 1486-1588

•Prevention of sudden death in asymptomatic patients with none of the five findings above (III)

Aortic Stenosis < 1 cm2

SymptomsAnd normal or subnormal LVEF

Low output Asymptomatic

AVR Dobutamine Echo Exercise Test

Severe Aortic stenosis (<1 cm2 or 0.6 cm2/ m2) without symptoms

Echocardiography

Negative : close monitoring

Aortic Valve Replacement

-Peak jet velocity > 4m/s and Progression of PV > 0.3m/s/year and rather severe calcifications-Ventricular arrythmia-> 15 mm Wall thickness

Positive

Exercise test BNP ?Exercise Echocardiography ?