eMedicine Specialties > Cardiology > Valvular Heart Disease

Aortic Stenosis: Treatment & Medication

Author: John A McPherson, MD, FACC, FSCAI, Assistant Professor of Medicine, Division of Cardiovascular Medicine, Medical Director of Cardiovascular Intensive Care Unit, Vanderbilt Heart and Vascular Institute
Contributor Information and Disclosures

Updated: Aug 25, 2009

Treatment

Medical Care

The primary management of symptomatic patients with valvular aortic stenosis is interventional. Medical treatment essentially is reserved for patients who have complications of aortic stenosis such as heart failure, infective endocarditis, hypertension or arrhythmias.

  • Digitalis can be used as an inotropic agent and to control the ventricular rate in patients with atrial fibrillation. Diuretics may be used for pulmonary congestive symptoms, and vasodilators may be used for heart failure and for hypertension. Both classes of agents should be used with extreme caution to avoid critically reducing preload or systemic arterial blood pressure in a patient with significant aortic stenosis.
  • Antibiotic prophylaxis is no longer indicated for the prevention of infective endocarditis in patients with aortic stenosis.
  • Severe hypertension is frequently seen in the elderly patient with aortic stenosis and should be treated because it causes an additional increase in vascular afterload. Treatment to reduce blood pressure according to JNC guidelines is recommended. Reducing the blood pressure to normal levels is advisable but hypotension must be avoided.1
  • Recently, several small observational studies suggested that HMG-CoA reductase inhibitor use can reduce aortic valve leaflet calcification and delay the progression of aortic stenosis severity.2

Surgical Care

The primary management of symptomatic patients with valvular aortic stenosis is interventional. The timing of intervention is determined by the severity of the stenosis and the presence of symptoms. Once symptoms develop and severe aortic stenosis is demonstrated, intervention is needed. In asymptomatic patients with severe aortic stenosis, follow-up is needed every 6 months.

  • Percutaneous balloon valvuloplasty is used as a palliative measure in critically ill adult patients who are not surgical candidates or as a bridge in critically ill patients before they undergo aortic valve replacement.
  • The high rate of restenosis and the absence of a mortality benefit preclude its use as a definitive treatment method in adults with severe aortic stenosis.
    • Valvuloplasty can be considered in patients with severe congestive heart failure or cardiogenic shock (1) as a bridge to valve replacement as a palliative measure, (2) for patients with other comorbid conditions with a very short life expectancy, (3) for those who refuse surgery, (4) for those with heart failure who need an urgent major noncardiac surgical procedure, or (5) in pregnant patients with critical aortic stenosis.
    • In critically ill patients, the mortality rate associated with the procedure is 3-7%. Another 6% develop serious complications including perforation, myocardial infarction, and severe aortic regurgitation.
  • In children, adolescents, and young adults with congenital aortic stenosis, percutaneous balloon valvuloplasty is an accepted alternative to surgical valvotomy and carries a risk of 1%.
    • The best results from valvuloplasty are obtained in the patients with a commissural bicuspid aortic valve, where a 60-70% reduction in gradient and a 60% increase in AVA can be expected.
    • It is recommended for patients with gradients higher than 50-60 mm Hg and/or a valve area of less than 0.5 cm2/m2, even in asymptomatic patients, because of the low risk associated with balloon valvuloplasty, the high desire for unrestricted or minimally limited lifestyle in younger populations, and the incidence of certain rare cases of sudden cardiac death.
    • Restenosis is common, particularly in patients with unicuspid valves or with valves affected by severe dysplasia (>60% at 6 mo, virtually 100% at 2 y). The risk rate of causing significant aortic regurgitation is 10%.
    • More than mild aortic regurgitation poses a contraindication for this procedure.
  • Aortic valve replacement
    • ACC/AHA recommendations for aortic valve replacement in patients with valvular aortic stenosis are summarized in Table 5. In most adults with symptomatic severe aortic stenosis, aortic valve replacement is the surgical treatment of choice. If concomitant coronary disease is present, aortic valve replacement and coronary artery bypass graft (CABG) should be performed simultaneously. Successful aortic valve replacement produces substantial clinical and hemodynamic improvement in patients with aortic stenosis, including octogenarians. Aortic valve replacement should be performed in all symptomatic patients with severe aortic stenosis regardless of LV function as survival is better with surgical treatment than with medical treatment.
    • Aortic valve replacement is also recommended in asymptomatic patients with severe aortic stenosis and LV dysfunction. Improvement in EF invariably occurs over the following 6 months, and increased LV mass tends to decrease within 18 months postoperatively.
    • The choice of prosthesis is determined by the anticipated longevity of the patients and their ability to tolerate anticoagulation.
    • The surgical mortality risk in patients with normal LV systolic function and no other comorbid conditions is less than 5%. Risk factors for increased operative mortality include (1) high New York Heart Association (NYHA) class (25-30% mortality in patients with class IV), (2) preoperative LV systolic dysfunction, (3) age, and (4) the presence of associated aortic regurgitation.
    • Overall, the 5-year survival rate in all adults after aortic valve replacement is 80-94%, and the 10-year survival rate is 68-89%. Risk factors for late death include high preoperative NYHA class, LV systolic dysfunction, preoperative ventricular arrhythmias, concomitant aortic regurgitation, atrial fibrillation and coronary artery disease, particularly a history of myocardial infarction.
    • Table 5. Recommendations for Aortic Valve Replacement in Aortic Stenosis

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      Table
      IndicationClass
      Symptomatic patients with severe ASI
      Patients with severe AS undergoing
      coronary artery bypass surgery      		I
      Patients with severe AS undergoing surgery on the aorta or other heart valvesI
      Patients with moderate AS undergoing coronary artery bypass surgery or surgery on the aorta or other heart valvesIIa
      Asymptomatic patients with severe AS and the following:
      LV systolic dysfunctionIIa
      Abnormal response to exercise (eg, hypotension)IIa
      Ventricular tachycardiaIIb
      Marked or excessive LVH (>15 mm)IIb
      Valve area <0.6 cm2 IIb
      Prevention of sudden death in asymptomatic patients with none of the findings listed under asymptomatic patients with severe ASIII
      IndicationClass
      Symptomatic patients with severe ASI
      Patients with severe AS undergoing
      coronary artery bypass surgery      		I
      Patients with severe AS undergoing surgery on the aorta or other heart valvesI
      Patients with moderate AS undergoing coronary artery bypass surgery or surgery on the aorta or other heart valvesIIa
      Asymptomatic patients with severe AS and the following:
      LV systolic dysfunctionIIa
      Abnormal response to exercise (eg, hypotension)IIa
      Ventricular tachycardiaIIb
      Marked or excessive LVH (>15 mm)IIb
      Valve area <0.6 cm2 IIb
      Prevention of sudden death in asymptomatic patients with none of the findings listed under asymptomatic patients with severe ASIII
    • The Ross procedure is another option in young patients as an initial procedure or for reoperation after prior valvotomy. In this procedure, the patient's own pulmonary valve and main pulmonary artery are transplanted to the aortic position, with reimplantation of coronary arteries. A homograft is placed in the pulmonary position. Its durability is better than with tissue valves, and anticoagulation is not required. This procedure is technically demanding.
    • Recently, percutaneous transcatheter aortic valve replacement has been developed as an alternative to surgical aortic valve replacement in high-risk surgical patients. Delivery via antegrade, retrograde, and transapical approaches have been studied. To date, over 4,000 patients worldwide have been treated with the transcatheter approach, and there are ongoing clinical trials in the US.3 Although percutaneous aortic valve replacement may be an exciting alternative to the standard surgical approach, its use and long-term durability are unknown. At this time, it should only be performed as part of an investigational study.

Activity

Patients with mild AS can lead a normal life. In cases of moderate AS, moderate-to-severe physical exertion and competitive sports should be avoided.

Medication

Treatment of valvular AS is interventional. When intervention is not an option, signs of heart failure must be treated with inotropic therapy, diuretics, and nitrates. Antibiotic prophylaxis for the prevention of bacterial endocarditis is no longer recommended in patients with valvular aortic stenosis.4

More on Aortic Stenosis

Overview: Aortic Stenosis
Differential Diagnoses & Workup: Aortic Stenosis
Treatment & Medication: Aortic Stenosis
Follow-up: Aortic Stenosis
Multimedia: Aortic Stenosis
References
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References

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Further Reading

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Keywords

aortic stenosis, AS, valvular aortic stenosis, valvular AS, aorta stenosis, aortic valve surgery, heart failure, syncope, angina pectoris, pulsus parvus et tardus, heart valve obstruction, aortic obstruction, aortic valve obstruction, aortic valve replacement, AVR, sudden cardiac death, SCD, calcific embolization, infective endocarditis

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Contributor Information and Disclosures

Author

John A McPherson, MD, FACC, FSCAI, Assistant Professor of Medicine, Division of Cardiovascular Medicine, Medical Director of Cardiovascular Intensive Care Unit, Vanderbilt Heart and Vascular Institute
John A McPherson, MD, FACC, FSCAI is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American Heart Association, Society for Cardiac Angiography and Interventions, Society of Critical Care Medicine, and Tennessee Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Alan D Forker, MD, Professor of Medicine, Program Director of Cardiovascular Fellowship, University of Missouri at Kansas City School of Medicine; Director, Outpatient Lipid Diabetes Research Center, MidAmerica Heart Institute of St Luke's Hospital
Alan D Forker, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American College of Physicians, American Heart Association, American Medical Association, American Society of Hypertension, and Phi Beta Kappa
Disclosure: Research Grant Grant/research funds Hospital contracts to do research; I am a hospital employee with no personal profit; Speakers Bureau Honoraria Speaking and teaching

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Steven J Compton, MD, FACC, FACP, Director of Cardiac Electrophysiology, Alaska Heart Institute, Providence and Alaska Regional Hospitals
Steven J Compton, MD, FACC, FACP is a member of the following medical societies: Alaska State Medical Association, American College of Cardiology, and American College of Physicians
Disclosure: Nothing to disclose.

CME Editor

Amer Suleman, MD, Consultant in Electrophysiology and Cardiovascular Medicine, Department of Internal Medicine, Division of Cardiology, Medical City Dallas Hospital
Amer Suleman, MD is a member of the following medical societies: American College of Physicians, American Heart Association, American Institute of Stress, American Society of Hypertension, Federation of American Societies for Experimental Biology, Royal Society of Medicine, and Society of Cardiac Angiography and Interventions
Disclosure: Nothing to disclose.

Chief Editor

Richard A Lange, MD, Professor and Executive Vice Chairman, Department of Medicine, University of Texas Health Science Center at San Antonio
Richard A Lange, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American Heart Association, and Association of Subspecialty Professors
Disclosure: Nothing to disclose.

 
 
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