Guidelines in clinical practice

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2017 ESC/EACTS Treatment Guidelines1

Early intervention is strongly recommended, for patients:

See the 2017 ESC/EACTS recommendations on the management of severe aortic stenosis (sAS)

Management of severe symptomatic aortic stenosis

TAVI Management of severe AS diagram
Further details on the management of valvular heart disease are available on ESC website

EuroSCORE II determines treatment choices

Choice of intervention for severe aortic stenosis (sAS), based on ESC/EACTS Guidelines, is primarily governed by EuroScore II which can be influenced by:1, 3, 4

EuroScore II treatment choices

Frailty as a risk factor

Frailty is associated with increased morbidity and mortality after sAVR and TAVI, therefore careful assessment is important. Several tools (e.g. the Essential Frailty Toolset) can provide objective estimates of frailty. 1,5

Measures of frailty 4, 6
Essential frailty toolset 4, 6
Parameters
Points
Lower-extremity muscle weakness
Five chair rises

<15 seconds

0

>15 seconds

1

Unable to complete

2
Measures of frailty 4, 6
Lower-extremity muscle weakness
Essential frailty toolset 4, 6
Five chair rises
Parameters
Points

<15 seconds

0

>15 seconds

1

Unable to complete

2
Measures of frailty4, 6
Essential frailty toolset4, 6
Parameters
Points
Lower-extremity muscle weakness
Five chair rises

<15 seconds

0

>15 seconds

1

Unable to complete

2
Measures of frailty4, 6
Lower-extremity muscle weakness
Essential frailty toolset4, 6
Five chair rises
Parameters
Points

<15 seconds

0

>15 seconds

1

Unable to complete

2
Cognitive impairment
Mini-mental state examination

Score of > 24

0
Score of < 24*
1
Measures of frailty 4, 6
Cognitive impairment
Essential frailty toolset4, 6
Mini-mental state examination
Parameters
Points

Score of > 24

0
Score of < 24*
1
Cognitive impairement
Mini-mental state examination

Score of > 24

0

Score of < 24

1
Measures of frailty4, 6
Cognitive impairement
Essential frailty toolset4, 6
Mini-mental state examination
Parameters
Points

Score of > 24

0

Score of < 24

1
Low haemoglobin
Haemoglobin

Men      > 13.0 g/dL

Women > 12.0 g/dL

0

Men      < 13.0 g/dL

Women < 12.0 g/dL

1
Measures of frailty 4, 6
Low haemoglobin
Essential frailty toolset4, 6
Haemoglobin
Parameters
Points

Men      > 13.0 g/dL

Women > 12.0 g/dL

0

Men      < 13.0 g/dL

Women < 12.0 g/dL

1
Low haemoglobin
Haemoglobin

Men > 13.0 g/dL

Women > 12.0 g/dL

0

Men < 13.0 g/dL

Women < 12.0 g/dL

1
Measures of frailty4, 6
Low haemoglobin
Essential frailty toolset4,6
Haemoglobin
Parameters
Points

Men > 13.0 g/dL

Women > 12.0 g/dL

0

Men < 13.0 g/dL

Women < 12.0 g/dL

1
Low serum albumin
Serum albumin

Score of >3.5 g/dL

0

Score of <3.5 g/dL

1
Measures of frailty 4, 6
Low serum albumin
Essential frailty toolset4, 6
Serum albumin
Parameters
Points

Score of >3.5 g/dL

0

Score of <3.5 g/dL

1
Low serum albumin
Serum albumin

Score of >3.5 g/dL

0

Score of <3.5 g/dL

1
Measures of frailty4, 6
Low serum albumin
Essential frailty toolset4, 6
Serum albumin
Parameters
Points

Score of >3.5 g/dL

0

Score of <3.5 g/dL

1

The EFT is scored 0 to 5. Frailty is defined as ≥3 of 5 points, with severe frailty defined as 5 of 5. 

*Score <24 on the mini-mental state examination is highly unlikely if the patient is able to correctly recall 3 out of 3 words after a distractive task and may obviate the need for further cognitive testing.

Latest evidence from the PARTNER 3 Trial and 2020 consensus statements

Since the 2017 ESC/EACTS guidelines were released, the PARTNER 3 Trial data has been presented showing superior* outcomes compared to surgery in low surgical risk patients, and supported the expanded TAVI indication into low-risk sAS patients.This data will be considered in future guideline updates but until then consensus statements can support these gaps between updates.

*The PARTNER 3 Trial proved SAPIEN 3 TAVI is superior to surgery on the primary endpoint (all-cause death, stroke, rehospitalisation) and multiple pre-specified endpoints in low-risk patients.
The 2020 consensus paper from the German Society for Cardiology (DGK) and the German Society for Thoracic, Cardiac and Vascular Surgery (DGTHG) on TAVI recommends:2
≤ 70
years old
sAVR
70 - 75
years old
TAVI
evaluation
> 75
years old
TAVI

Use the latest guideline evidence and consensus data to inform the referral and treatment pathway for patients with severe aortic stenosis.

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References

  • 1 Baumgartner H, Falk V, Bax JJ et al. Eur Heart J 2017;38(36):2739–2791.
  • 2 Kuck K et al. Cardiologist 2020;14:182-204.
  • 3 Muñoz A et al. ESC E-Journal of Cardiology Practice 2016; 14:3.
  • 4 Afilalo J, et al. J Am Coll Cardiol 2017; 70:689-700.
  • 5 Thongprayoon C et al. Ann Transl Med 2017;5(6):144.
  • 6 Mack MJ et al. J Am Coll Cardiol 2017;70:701-703.
  • 7 Mack MJ, et al. N Engl J Med 2019;380(18):1695-1705.

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