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 ?