Aortic Stenosis Guidelines

Updated: Mar 24, 2017
  • Author: Xiushui (Mike) Ren, MD; Chief Editor: Richard A Lange, MD, MBA  more...
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Guidelines

Guidelines Summary

In 2014, the American College of Cardiology (ACC)/American Heart Association (AHA) released a revision to its 2008 guidelines for management of patients with valvular heart disease (VHD) [5] ; and the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) issued a revision of its 2007 guidelines in 2012. [4]  The Society of Thoracic Surgeons (STS) published guidelines for the management of aortic valve disease in 2013. [46]

The 2014 AHA/ACC guidelines classify progression of valvular aortic stenosis (AS) into 4 stages (A to D), as summarized below. [5] :

Stage A: At risk of AS

Stage B: Progressive AS 

Stage C: Asymptomatic severe AS, as follows:

  • C1: Asymptomatic severe AS
  • C2: Asymptomatic severe AS with LV dysfuntion

Stage D: Symptomatic severe AS, as follows

  • D1 Symptomatic severe high-gradient AS
  • D2 Symptomatic severe low flow/low gradient AS with reduced left ventricular ejection fraction (LVEF)
  • D3 Symptomatic severe low gradient AS with normal LVEF or paradoxical low flow severe AS

According to the 2012 ESC/EACTS guidelines, the echocardiographic criteria for defining severe AS also include valve area less than 1.0 cm2, mean gradient greater than 40 mm Hg, and maximum jet velocity greater than 4 m per second. [4]

Both the AHA/ACC and ESC/EACTS guidelines require intervention decisions for severe VHD be based on an individual risk-benefit analysis. Improved prognosis should outweigh the risk of intervention and potential late consequences, particularly complications related to prosthetic valves. [4, 5]

Recognizing the known limitations of the EuroSCORE (European System for Cardiac Operative Risk Evaluation) and the STS score, the AHA/ACC guidelines suggest using the STS criteria plus three additional indicators: frailty (using accepted indices), major organ system compromise not improved postoperatively, and procedure-specific impediment when assessing risk. [5]  

The 2014 AHA/ACC updated guidelines recommendations for AS include the following [5, 47] :

  • Patients with signs or symptoms of AS or a bicuspid aortic valve should be evaluated with transthoracic echocardiography (TTE); selected patients with stage D2 AS may be evaluated with low-dose dobutamine stress testing
  • Hypertension should be treated in patients at risk for, and with, asymptomatic AS
  • Surgical aortic valve replacement (AVR) is recommended for patients who meet an indication for AVR  as summarized below, in Table 3. 

According to the ESC/EACTS guidelines, aortic valve replacement should be performed in all symptomatic patients with severe AS, regardless of left ventricular (LV) function, as survival is better with surgical treatment than with medical treatment. [4]  

Table 3. Indications for Aortic Valve Replacement in Aortic Stenosis (Open Table in a new window)

Indication Class
Symptomatic severe high-gradient AS (Stage D1) I
Asymptomatic severe AS (Stage C2) with and LVEF <50% I
Severe AS (Stage C or D) undergoing other cardiac surgery  I
Asymptomatic, very severe AS (Stage C1, aortic velocity ≥5.0 m/s) and low surgical risk IIa
Asymptomatic, severe AS (Stage C1) and decreased expercise tolerance or an exercise fall in blood pressure IIa
Symptomatic severe low flow/low gradient AS with reduced LVEF (Stage D2) with a low-dose dobutamine stress study with aortic velocity ≥4.0 m/s with a value are ≤1.0 cmat any dobutamine dose IIa
Symptomatic severe low flow/low gradient AS (Stage D3) who are normotensive and have an LVEF ≥50% if clinical, hemodynamic and anantomic data support valve obstruction as the most likely cause of symptoms IIa
Moderate AS (Stage B) who are undergoing other cardiac surgery IIa
Asymptomatic  severe AS (Stage C1) with rapid disease progression and low surgical risk IIb

A comparison of recommendations for surgical and transcatheter intervention for AS is provided in Table 4, below.

Table 4. Guideline Recommendations for Aortic Stenosis Intervention (Open Table in a new window)

Intervention Selection AHA/ACC (2014) [5] ESC/EACTS (2012) [4] STS(2013) [46]
Surgical AVR in patients with low or intermediate surgical risk Class I Class I  
Transcatheter aortic valve replacement (TAVR) for patients who have a prohibitive surgical risk and a predicted post-TAVR survival >12 mo Class I Class I Class I
TAVR for patients who have high surgical risk Class IIa-Reasonable Class IIa-Reasonable  
TAVR is not recommended in patients in whom existing comorbidities would preclude the expected benefit from correction of AS Class III Class III  
Balloon aortic valvuloplasty (BAV) as a bridge to surgical AVR or TAVR in severely symptomatic patients Class IIb-Consider Class IIb-Consider Class IIa-Reasonable
BAV as bridge to AVR in hemodynamically unstable patients with severe AS where immediate AVR is not feasible   Class IIb-Consider Class IIa-Reasonable
BAV in severely symptomatic patients where AVR is not an option for symptom relief     Class IIb-Consider
BAV as a palliative measure when surgery is contraindicated because of severe comorbidities   Class IIb-Consider Class IIb-Consider

In the 2014 joint guidelines on the management of atrial fibrillation (AF), the American College of Cardiology Foundation, American Heart Association, and Heart Rhythm Society (ACCF/AHA/HRS) recommended against the use of dabigatran in patients with AF and a mechanical heart valve. (Class III) [48]