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Exercise Testing Unmasking AS Symptoms — EECC MCQ

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ModerateValvular Heart DiseaseExercise Testing Unmasking AS SymptomsEECC

A 68-year-old man with severe AS undergoes stress echocardiography. He is asymptomatic at rest but develops dyspnoea and a fall in blood pressure (from 130/80 to 110/70 mmHg) at peak exercise. The mean gradient rises from 42 to 68 mmHg during exercise. What is the significance?

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Correct answer: B — Exercise-induced symptoms and/or abnormal BP response (failure to rise or fall in SBP) in asymptomatic severe AS unmask occult symptoms and predict adverse events — this finding upgrades the patient from 'asymptomatic' to 'symptomatic' and meets Class I criteria for valve intervention

Exercise testing in asymptomatic severe AS (performed under supervised conditions — NOT contraindicated if the patient is truly asymptomatic) can unmask: (1) exercise-induced symptoms (dyspnoea, angina, presyncope — classify patient as 'symptomatic' → Class I for intervention); (2) abnormal BP response: failure to increase SBP by ≥20 mmHg or actual SBP fall during exercise — a marker of inadequate cardiac output reserve and predictor of symptom onset/adverse events within 12 months; (3) exercise-induced arrhythmias; (4) excessive gradient rise (>18-20 mmHg increase from rest to exercise). The 2025 ESC VHD Guidelines recommend exercise testing for all physically active patients with asymptomatic severe AS to identify those who should proceed to intervention rather than waiting for spontaneous symptoms (which may present as sudden death in 1-2%). This patient's exercise-induced dyspnoea + BP drop = Class I for AVR.

Reference: ESC/EACTS (2025): VHD Guidelines