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Otto et al 2020 ACC/AHA Guideline for the Management of Valvular Heart Disease Circulation. 2021;143:e72–e227. DOI: 10.1161/CIR.0000000000000923 February 2, 2021 e93 CLINICAL STATEMENTS AND GUIDELINES is calculated with the Gorlin formula by using a Fick or thermodilution cardiac output measurement. See Section 14.1 for recommendations on coronary angiography in patients with AS.1,2 3.2.1.5 Diagnostic Testing: Exercise Testing Recommendations for Diagnostic Testing: Exercise Testing in Patients With AS Referenced studies that support the recommendations are summarized in Online Data Supplement 4. COR LOE Recommendations 2a B-NR 1. In asymptomatic patients with severe AS (Stage C1), exercise testing is reasonable to assess physiological changes with exercise and to confirm the absence of symptoms.1–4 3: Harm B-NR 2. In symptomatic patients with severe AS (Stage D1, aortic velocity ≥4.0 m/s or mean pressure gradient ≥40 mm Hg), exercise testing should not be performed because of the risk of severe hemodynamic compromise.5 Synopsis In a subset of asymptomatic patients with severe AS, exercise testing can provide additional diagnostic and prognostic information, but it should not be performed in symptomatic patients with severe AS. Recommendation-Specific Supportive Text 1. When performed under the direct supervision of an experienced clinician, with close monitoring of blood pressure and ECG, exercise testing in asymptomatic patients is relatively safe and may provide information that is not evident during the initial clinical evaluation, particularly when the patient’s functional capacity is unclear. Patients with symptoms provoked by exercise testing should be considered symptomatic, even if the clinical history is equivocal. Although it can be challenging to separate normal exercise limitations from abnormal symptoms that are attributable to AS, particularly in elderly sedentary patients, exercise-induced angina, excessive dyspnea early in exercise, dizziness, and syncope are consistent with symptoms of AS. Exercise testing can also identify a limited exercise capacity or an abnormal blood pressure response. Recording aortic valve hemodynamics with exercise is of limited value and does not show additive value for predicting clinical outcome when baseline measures of hemodynamic severity and functional status are considered. In addition, recording hemodynamics with exercise is challenging, and simpler parameters are adequate in most patients.2–4,6–11 2. As reported in several prospective and retrospective studies, the risk of exercise testing is low in asymptomatic patients with AS. However, exercise testing is avoided in symptomatic patients with AS because of a high risk of complications, including syncope, ventricular tachycardia, and death. In a prospective survey of 20 medical centers in Sweden that included 50 000 exercise tests done over an 18-month period, the complication rate was 18.4 per 10 000 tests; morbidity rate, 5.2 per 10 000 tests; and mortality rate, 0.4 per 10 000 tests. Although the number of patients with AS was not reported, 12 of the 92 complications occurred in patients with AS: 8 had a decline in blood pressure during exercise, 1 had asystole, and 3 had ventricular tachycardia.2,4,5,7–10,12 3.2.2 Medical Therapy Recommendations for Medical Therapy of AS Referenced studies that support the recommendations are summarized in Online Data Supplement 5. COR LOE Recommendations 1 B-NR 1. In patients at risk of developing AS (Stage A) and in patients with asymptomatic AS (Stages B and C), hypertension should be treated according to standard GDMT, started at a low dose, and gradually titrated upward as needed, with appropriate clinical monitoring.1–3 1 A 2. In all patients with calcific AS, statin therapy is indicated for primary and secondary prevention of atherosclerosis on the basis of standard risk scores.4–6 2b B-NR 3. In patients who have undergone TAVI, renin–angiotensin system blocker therapy (ACE inhibitor or ARB) may be considered to reduce the long-term risk of all-cause mortality.7,8 3: No Benefit A 4. In patients with calcific AS (Stages B and C), statin therapy is not indicated for prevention of hemodynamic progression of AS.4–6 Synopsis Medical treatment of hypertension and hyperlipidemia according to GDMT is appropriate for patients with AS. ACE inhibitor or ARB treatment may reduce the mortality rate in patients with AS who underwent TAVI. Recommendation-Specific Supportive Text 1. Hypertension is common in patients with AS, may be a risk factor for AS, and adds to the total pressure overload on the LV in combination with valve obstruction. Concern that antihypertensive medications might result in a decrease in cardiac output has not been corroborated in studies of medical therapy, including 2 small RCTs, likely because AS does not result in “fixed” valve obstruction until late in the disease process. In 1616 patients Downloaded from http://ahajournals.org by on October 7, 2026