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Asymptomatic Aortic Stenosis and Exercise Test

Asymptomatic Aortic Stenosis and Exercise Test. Euro Heart Survey on Valvular Heart Disease 1. « 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

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Asymptomatic Aortic Stenosis and Exercise Test

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  1. Asymptomatic Aortic Stenosis and Exercise Test

  2. 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

  3. Exercise tests performed AS AR MS MR ET6.7%12.2% 7.4% 11.3% AS : 5.7% of asymptomatic patients : under-utilisation 3.2% of NYHA3 et 4 patients: ????? (1) Iung et al.ESC survey on valvular heart disease. Eur Heart J 2003; 24 : 1231-43

  4. 20,7 % « overused » of intervention Comparison surgical indication/ guidelines2 (2) Iung et al. Recommendations on the management of the asymptomatic patients with valvular heart disease. Eur Heart J 2002; 23 : 1253-66

  5. 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

  6. Mortality after Aortic Valve Replacement Rahimtoola. Circulation 2000; IV.24-33

  7. But dont operate too late … Valve replacement No surgery (Symptomatic Aortic Stenosis) Scwartz E. Circulation 1982; 66 : 1105-10

  8. 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

  9. Exercise test indications in AS(2) • Identifying coronary heart disease : none • Asymptomatic patients : • Strongly recommended1,2 • 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

  10. First study : Feasibility :OTTO 1997 • 123 asymptomatic patients • Followed 2.5 + 1.4 years • End points : death or AVR Circulation 1997; 95 : 2262-70

  11. 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 ?

  12. 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

  13. 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

  14. 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

  15. Valvular area Positive ET

  16. 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 Conclusion : Aortic valve replacement can be postponed in asymptomatic patients with negative ET Heart 2001; 86 : 381-6

  17. Other studies • Alborino1 • N = 30 • Lancellotti2 • N = 63 • Exercise echocardiography • Alborino. J Heart Valve Dis 2002; 11 : 204-209 • Lancellotti . AHA 2004; abstr n° 3279

  18. 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 patients With valvular heart disease. Eur Heart J 2002; 23 : 1253-66

  19. 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) • Prevention of sudden death in asymptomatic patients • with none of the five findings above (III) Bonow R et al.ACC/AHA Guidelines for the management of patients with valvular heart disease. JACC 1998; 32(5) : 1486-1588

  20. Symptoms And normal or subnormal LVEF Low output Asymptomatic Dobutamine Echo AVR Exercise Test Aortic Stenosis < 1 cm2

  21. Echocardiography Severe Aortic stenosis (<1 cm2 or 0.6 cm2/ m2) without symptoms BNP ? Exercise Echocardiography? Exercise test Positive Negative : close monitoring -Peak jet velocity > 4m/s and Progression of PV > 0.3m/s/year and rather severe calcifications -Ventricular arrythmia -> 15 mm Wall thickness Aortic Valve Replacement

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