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Otto et al 2020 ACC/AHA Guideline for the Management of Valvular Heart Disease

February 2, 2021 Circulation. 2021;143:e72–e227. DOI: 10.1161/CIR.0000000000000923 e94

CLINICAL STATEMENTS AND GUIDELINES with asymptomatic AS in the SEAS (Simvastatin Ezetimibe in Aortic Stenosis) study, hypertension (n=1340) was associated with a 56% higher rate of ischemic cardiovascular events and a 2-fold higher mortality rate (both P<0.01) than those seen in normotensive patients with AS, although no impact on progression of valve stenosis leading to symptoms requiring AVR was seen. Medical therapy for hypertension follows standard guidelines, starting at a low dose and gradually titrating upward as needed to achieve blood pressure control. There are no studies addressing specific antihypertensive medications in patients with AS, but diuretics may reduce stroke volume, particularly if the LV chamber is small at baseline. In theory, ACE inhibitors may be advantageous because of the potential beneficial effects on LV fibrosis, in addition to control of hypertension. Consideration should be given to a higher target blood pressure for patients with AS than is recommended for the general population, but this is an underexplored area, and further data are needed before a different target blood pressure can be recommended for patients with AS.1–3,9–13

2.	 Concurrent CAD is common in patients with AS, and all patients should be screened and treated for hypercholesterolemia, with GDMT used for primary and secondary prevention of CAD. In RCTs of statin therapy for mild to moderate AS, although aortic valve event rates were not reduced, the rate of ischemic events was reduced by about 20% in the statin therapy group even though these patients did not meet standard criteria for statin therapy.4–6,14,15 3.	 In patients undergoing TAVI, observational and registry data show that those who were treated with renin–angiotensin system blocker therapy after the procedure had a lower 1-year mortality rate than those not treated with renin–angiotensin system blocker therapy, with a relative risk reduction of about 20% to 50% and an absolute risk reduction between 2.4% and 5.0%. When stratified by LVEF, having a prescription for a renin–angiotensin system inhibitor, versus no prescription, was associated with a lower 1-year mortality rate among patients with preserved LVEF but not among those with reduced LVEF.7,8,16,17 4.	 Despite experimental models and retrospective clinical studies suggesting that lipid-lowering therapy with a statin might prevent disease progression of calcific AS, 3 large well-designed RCTs failed to show a benefit, either in terms of changes in hemodynamic severity or in clinical outcomes, in patients with mild to moderate valve obstruction. Thus, at the time of publication, there are no data to support the use of statins for prevention of progression of AS.7,8,16,17

3.2.3 Timing of Intervention

Recommendations for Timing of Intervention of AS Referenced studies that support the recommendations are summarized in Online Data Supplements 4 and 6 to 10.

COR LOE Recommendations

1 A 1 In adults with severe high-gradient AS (Stage

D1) and symptoms of exertional dyspnea, HF, angina, syncope, or presyncope by history or on exercise testing, AVR is indicated.1–7

1 B-NR 2 In asymptomatic patients with severe AS

and an LVEF <50% (Stage C2), AVR is indicated.8–11

1 B-NR 3 In asymptomatic patients with severe AS

(Stage C1) who are undergoing cardiac surgery for other indications, AVR is indicated.12–16

1 B-NR 4 In symptomatic patients with low-flow, low-

gradient severe AS with reduced LVEF (Stage D2), AVR is recommended.17–24

1 B-NR 5 In symptomatic patients with low-flow, low-

gradient severe AS with normal LVEF (Stage D3), AVR is recommended if AS is the most likely cause of symptoms.25–27

2a B-NR 6 In apparently asymptomatic patients with

severe AS (Stage C1) and low surgical risk, AVR is reasonable when an exercise test demonstrates decreased exercise tolerance (normalized for age and sex) or a fall in systolic blood pressure of ≥10 mm Hg from baseline to peak exercise.13,28–30

2a B-R 7 In asymptomatic patients with very severe AS

(defined as an aortic velocity of ≥5 m/s) and low surgical risk, AVR is reasonable.15,31–35

2a B-NR 8 In apparently asymptomatic patients with severe

AS (Stage C1) and low surgical risk, AVR is reasonable when the serum B-type natriuretic peptide (BNP) level is >3 times normal.32,36–38

2a B-NR 9 In asymptomatic patients with high-gradient

severe AS (Stage C1) and low surgical risk, AVR is reasonable when serial testing shows an increase in aortic velocity ≥0.3 m/s per year.39,40

2b B-NR 10.  In asymptomatic patients with severe highgradient AS (Stage C1) and a progressive decrease in LVEF on at least 3 serial imaging studies to <60%, AVR may be considered.8–11,33

2b C-EO 11.  In patients with moderate AS (Stage B) who are undergoing cardiac surgery for other indications, AVR may be considered.

Synopsis

See the table of recommendations for a summary of recommendations from this section and Figure  2 for indications for AVR in patients with AS. These recommendations for timing of intervention for AS apply to both SAVR and TAVI. The integrative approach to assessing risk of SAVR or TAVI is discussed in Section 2.5. The specific type of intervention for AS is discussed in Section 3.2.4.

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