Avoiding the risk of missed symptoms in patients with asymptomatic aortic stenosis (AS)

Patients often reduce physical activity to avoid symptoms, making it challenging to correctly identify when symptoms do develop. ^1-4 The added burden of COVID-19 risks exacerbating this through the risk of reduced hospital appointments and limited physical activity during lockdowns^5,6
It is critical to identify patients early, yet symptoms may be missed in nearly half of all severe AS (sAS) patients previously described as asymptomatic^2,7
Stress testing – either through exercise or by pharmacological means - could expose symptoms that are not apparent at rest⁴

The importance of timely referral

Timely and prompt identification of symptoms in patients with sAS is critical for avoiding sudden death and ensuring they receive the treatment they need.^1,2,8

However, up to 50% of patients with sAS report no symptoms at the time of diagnosis and more than 80% are unable to identify the key symptoms, which can make detecting their onset and the optimal timing for intervention a challenge. Correctly identifying symptom onset can be difficult for a number of reasons, including:^1,2,4

A sedentary lifestyle due to the older age of patients and lockdowns during COVID-19
Symptoms being attributed to other conditions or masked by a sedentary lifestyle due to the older age of patients
The variable and unpredictable nature of AS

Watch Professor Bernard Prendergast discuss the importance of correctly identifying patients with asymptomatic sAS, as well as the different diagnostic and treatment options available.

Professor Bernard Prendergast

6 min

Undetected symptoms can put patients’ lives at increased risk^1,2,7

Despite a lack of symptoms, patients with asymptomatic sAS may still need urgent treatment. Symptom-free survival at 12 months was 49% for patients with limiting symptoms on exercise testing and 89% for those without.⁷

The consequences of late diagnosis of symptoms by not stress testing asymptomatic patients can be serious. In a prospective study of patients with supposed asymptomatic sAS:¹

There was an 81% probability of patients experiencing an event (mortality or the development of symptoms)
6% experienced sudden death

Especially when patients do display symptoms the urgency to treat remains, as — if left untreated — the risk of death increases three-fold within the first 6 months.³

Event-free survival in patients with asymptomatic sAS according to exercise testing¹

Take a closer look at diagnosing AS and how to unmask symptoms in patients who appear asymptomatic

Using a stress test to expose symptoms in asymptomatic patients

One way to effectively detect if a patient’s condition is worsening and requires urgent treatment is with a stress test. Yet, studies show that stress tests were given in less than 5% of asymptomatic patients with AS.¹⁰

The ESC/EACTS guidelines recommend that stress testing is performed as part of the 6-monthly assessments in patients with asymptomatic sAS.¹¹ Stress testing can be performed with exercise or by pharmacological means depending on the patient’s ability.⁴

Exercise testing is considered the optimal method for assessing patients who are able to exercise and has been shown to be safe for patients with asymptomatic sAS:⁴

Exercise testing can be conducted either by treadmill or bicycle.

Pharmacological testing provides an alternative mode of stress testing in the ~15% of patients with symptomatic sAS who cannot exercise. For these patients, the administration of dobutamine can be used to mimic the effect of exercise on the heart.⁴

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References

1Amato MCM, et al. Heart 2001;86(4):381—386.
2Généreux P, et al. J Am Coll Cardiol. 2016;67(19):2263—2288.
3Malaisrie SC, et al. Ann Thorac Surg. 2014;98:1564—1571.
4Redfors B, et al. Circulation. 2017;135(20):1956—1976.
5Ammar A, et al. Nutrients. 2020;12(6):1583.
6Shah RB, et al. Catheter Cardiovasc Interv. 2020;96(3):659—663.
7Das P et al. Eur Heart J. 2005;26(13):1309—1313.
8Brown ML, et al. J Thorac Cardiovasc Surg. 2008;135(2):308—315.
9Thoenes M, et al. J Thorac Dis. 2018; 10(9): 5584—5594.
10Iung B, et al. Circulation 2019;140(14):1156—1169.
11Baumgartner H, et al. Eur Heart J. 2017;38(36):2739—2791.

Avoiding the risk of missed symptoms in patients with asymptomatic aortic stenosis (AS)

The importance of timely referral

Professor Bernard Prendergast

Undetected symptoms can put patients’ lives at increased risk1,2,7

Event-free survival in patients with asymptomatic sAS according to exercise testing1