Asymptomatic Aortic Stenosis and Exercise Test
Nov 18, 2014
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 ?