Challenges in treating patients with asymptomatic severe aortic stenosis (sAS)

  • Roughly 1/3 of patients with severe aortic stenosis (sAS) are asymptomatic and once symptoms develop their average survival declines1,2

  • Symptom detection is difficult with many patients attributing them to other factors3,4. Exercise testing is important for unmasking symptoms in patients with asymptomatic sAS5

  • Treatment is recommended in patients with asymptomatic severe aortic stenosis in the presence of one or more of these factors: adverse prognostic factors*, LVEF<50%, positive exercise test† or symptom development6

Prompt symptom identification in patients with sAS can be challenging3,4

Around 1/3 of patients with sAS aged 55 years or over are asymptomatic2 with a proportion of them under ‘watchful waiting’.6 Once symptoms develop, patients with sAS have an average survival of only 50% at 2 years and 20% at 5 years.1

However, identifying symptoms can be difficult as patients may:

 

  • Limit activities to avoid symptoms3
  • Attribute symptoms to comorbidities3
  • Think that symptoms e.g., breathlessness, are a normal part of ageing3,4

Help your patients record and monitor their symptoms with the Aortic Stenosis Symptom Tracker

Help your patients record and monitor their symptoms with the Aortic Stenosis Symptom Tracker

Exercise testing can unmask symptoms and help risk stratification6,7

Exercise testing in patients with asymptomatic sAS and a normal LVEF is recommended to unmask symptoms,6 with roughly half of patients expected to test positive.†5 Patients with limiting symptoms during exercise testing demonstrate 12-month-symptom-free survival of only 49% compared to 89% without.7

 

1 in 6 patients with symptomatic AS are unable to mobilise enough to perform an exercise stress test. Pharmacological stress testing with dobutamine alongside concomitant cardiac imaging is sometimes considered for these cases.3,5

Ongoing trial comparing early TAVR intervention with ‘watchful waiting’ in patients with asymptomatic sAS8

  • The timing of treatment for asymptomatic sAS is an evolving area in patient management.6,8-10 Unless patients with asymptomatic sAS develop symptoms,  adverse prognostic features*, an LVEF<50% or positive exercise test they undergo clinical surveillance through ‘watchful waiting’6
  • The EARLY TAVR trial is an ongoing randomised control study (N=901) evaluating the safety and effectiveness of the Edwards SAPIEN 3TM/SAPIEN 3 UltraTM transcatheter valve compared with clinical surveillance in patients with asymptomatic, calcific sAS.8

    The study started in July 2017 with an estimated primary completion date of March 20248

Objectives of the EARLY TAVR trial8

 

  • Primary endpoint: composite of all cause death, all stroke, and unplanned cardiovascular admission at 2-year follow up
  • Secondary endpoints: composite of alive and quality of life, left ventricular health, LVEF change from baseline, new-onset atrial fibrillation and death or disabling stroke at 2-year follow up

 

EARLY TAVR trial study design8,11

 

 

EARLY TAVR trial study design8,11

 

Check out our latest articles

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Key diagnostic steps in aortic stenosis (AS) echocardiography
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The 2021 ESC/EACTS guidelines recommend all* sAS patients with severe aortic stenosis are referred to the Heart Team1
Feb 2022 Read more

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References

AS, aortic stenosis; AVR, aortic valve replacement; LV, left ventricle; LVEF, left ventricular ejection fraction; sAS, severe aortic stenosis.

*       Adverse features according to clinical, imaging (echocardiography or CT scanning), and/or assessment of biomarkers.6
†       A positive result following exercise testing is the development of symptoms or a sustained blood pressure fall below the patient’s baseline.6

  • 1Otto CM. Heart. 2000;84:211–218.
  • 2Strange GA, et al. Open Heart. 2022;9:e001783.doi:10.1136/openhrt-2021-001783.
  • 3Redfors B, et al. Circulation. 2017;135(20):1956—1976.
  • 4Amato MCM, et al. Heart. 2001;86:381–386.
  • 5Généreux P, et al. J Am Coll Cardiol. 2016;67:2263–2268.
  • 6Vahanian A, et al. Eur Heart J. 2022;43(7):561-632.
  • 7Das P, Rimington H and Chambers J. Eur Heart J. 2005;26(13):1309-1313.
  • 8EARLY TAVR. Available at: https://clinicaltrials.gov/ct2/show/NCT03042104 (accessed April 2022)
  • 9Baumgartner H, Iung B and Otto CM. Eur Heart J. 2020;41:4349-4356.
  • 10Banovic M, et al. Circulation. 2022;45(1):648-658.
  • 11Edwards. Early TAVR Clinical Protocol. Version 5.0. 2021.
For professional use. For a listing of indications, contraindications, precautions, warnings, and potential adverse events, please refer to the Instructions for Use (consult eifu.edwards.com where applicable). Edwards devices placed on the European market meeting the essential requirements referred to in Article 3 of the Medical Device Directive 93/42/EEC bear the CE marking of conformity.

PP—EU-4175  v2.0

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