What management strategies should be implemented for a patient with asymptomatic aortic stenosis?

For a patient with asymptomatic aortic stenosis, several management strategies should be implemented, primarily focusing on specialist referral, monitoring, and consideration for intervention based on specific criteria.

• Specialist Referral: Adults diagnosed with moderate or severe aortic valve disease should be referred to a specialist ¹.
• Consideration for Intervention: For adults with asymptomatic severe aortic stenosis, intervention should be considered if suitable, particularly if they meet any of the following criteria on echocardiography: a peak aortic jet velocity (Vmax) greater than 5 m/s, an aortic valve area (AVA) less than 0.6 cm², or a left ventricular ejection fraction (LVEF) less than 55% ¹. Additionally, intervention should be considered if their B-type natriuretic peptide (BNP) or N-terminal proBNP (NT-proBNP) level is more than twice the upper limit of normal, or if symptoms are unmasked during exercise testing ¹. Recent clinical trials, such as the AVATAR trial and studies by Kang et al., have investigated the outcomes of early aortic valve replacement versus conservative treatment in asymptomatic severe aortic stenosis, contributing to the ongoing discussion on management strategies ¹, ((Kang et al., 2020)), ((Banovic et al., 2022)). The management of asymptomatic severe aortic stenosis, including guidelines and clinical outcomes, is an area of critical review ¹, ((Grbac et al., 2025)).
• Enhanced Follow-up: If mid-wall fibrosis is detected on cardiac MRI in adults with severe aortic stenosis, enhanced follow-up, such as more frequent reviews and further assessment (e.g., stress echocardiography), should be offered to monitor the need for intervention ¹.
• Patient Information and Support: It is crucial to provide information and advice to adults with valve disease about the expected progression and prognosis of their condition, including the likely length of the asymptomatic stage and any need for intervention ¹. Awareness of the psychological impact of a valve disease diagnosis is also important, and patients' needs for additional information and support should be considered ¹.
• Pregnancy Considerations: For women of childbearing potential, advice on the implications of treatment choices on any future pregnancy should be offered if heart valve intervention is needed ¹. Women with severe valve disease, particularly aortic stenosis, should be offered advice on family planning ¹. Pregnant women or those considering pregnancy with moderate or severe valve disease, or bicuspid aortic valve disease of any severity, should be referred to a cardiologist with expertise in the care of pregnant women, regardless of symptoms ¹.