Official reprint from UpToDate

www.uptodate.com 2014 UpToDate

Authors
Catherine M Otto, MD
Stephanie Cooper, MD
Section Editor
William H Gaasch, MD
Deputy Editor
Susan B Yeon, MD, JD, FACC
Medical management of symptomatic aortic stenosis
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: May 2014. | This topic last updated: Nov 13, 2013.
INTRODUCTION Aortic valve replacement (AVR) is the mainstay of treatment of symptomatic aortic stenosis
(AS). AVR offers substantial improvements in symptoms and life expectancy. Medical therapy may not prolong life
in patients with AS and has limited utility in treating symptoms.
In patients who are candidates for surgical intervention and are awaiting surgery, medical therapy to optimize
hemodynamics in the pre-operative setting may be needed. However, when severe symptoms are present, it may
be prudent to admit the patient to the hospital and perform surgery urgently, as there is a high risk of cardiac death
once severe symptoms are present.
Longer-term palliative medical management of symptomatic AS is appropriate for patients who are not candidates
for aortic valve surgery due to coexisting medical conditions and in patients who have refused AVR. Transcatheter
AVR (TAVR) allows intervention in some patients who are at too high risk to undergo surgical AVR, but in others,
TAVR may not be possible due to anatomic factors or may be futile due to a high level of comorbidities or frailty.
This topic will discuss medical management of patients with symptomatic AS and possible indications for aortic
valvuloplasty. Indications for AVR, surgical and transcatheter methods of AVR, and management of asymptomatic
AS are discussed separately. (See "Indications for valve replacement in aortic stenosis in adults" and "Surgical
valve replacement in aortic stenosis in adults" and "Medical management of asymptomatic aortic stenosis in
adults" and "Transcatheter aortic valve replacement".)
SETTINGS Aortic valve replacement (AVR) is recommended for patients with symptomatic aortic stenosis (AS).
(See "Indications for valve replacement in aortic stenosis in adults".) However, patients with symptomatic AS in the
following settings may require temporary or indefinite medical management.
Comorbid conditions AVR may not be appropriate in some patients with symptomatic AS due to certain
severe comorbid conditions, such as malignancy. In some cases, AVR may be deferred only temporarily while a
treatable condition (eg, infection) is managed and controlled.
High-risk patients Some patients are not candidates for valve replacement due to a very high risk for operative
mortality and morbidity. Some of these patients may be candidates for transcatheter aortic valve implantation but
others may not be able to undergo transcatheter AVR (TAVR) due to anatomic reasons (annulus size, vascular
access, etc) or the potential benefit of TAVR may be low due to a high level of comorbidities or frailty. (See
"Estimating the mortality risk of valvular surgery" and "Surgical valve replacement in aortic stenosis in adults" and
"Transcatheter aortic valve replacement".)
Patient refusal Some patients with symptomatic AS may refuse both surgical and TAVR despite adequate
counseling on the potential benefits and risks of AVR and deferral of intervention.
Care should be taken to ensure that AVR is offered to all appropriate patients with symptomatic AS with adequate
discussion of estimated risks. Of concern are reports that substantial numbers of patients with symptomatic AS
with reasonable estimated operative risks are not referred for aortic valve surgery [1,2]. (see "Indications for valve

replacement in aortic stenosis in adults" and "Estimating the mortality risk of valvular surgery").
Patients awaiting valve replacement In general, medical intervention prior to AVR should be minimized in
patients with symptomatic AS. Most medical interventions carry the risk of destabilizing the patient. Patients with
the onset of mild symptoms may be scheduled electively for valve replacement. However, those with frank heart
failure, angina, or syncope should be hospitalized while awaiting valve replacement. The management of critically ill
patients is discussed below. (See 'Critically ill patients awaiting valve replacement' below.)
Pregnancy Management of pregnant patients with symptomatic AS is discussed separately. (See "Pregnancy
in women with a bicuspid aortic valve", section on 'Bicuspid aortic stenosis'.)
MEDICAL MANAGEMENT
Severe symptomatic inoperable AS
General considerations Aortic valve replacement (AVR) for symptomatic aortic stenosis (AS) effectively
treats symptoms and prolongs life and should be considered in all patients. In contrast, when valve replacement is
not possible or is refused by the patient, medical therapy may not prolong life and has potential harm. The goals of
medical therapy are to treat concurrent cardiovascular conditions, prevent or treat superimposed diseases that often
exacerbate the effects of valve obstruction, maintain optimal loading conditions, and treat symptoms. In addition,
the physician should provide both the patient and family counseling about the expected disease course, treatment
options, and end-of-life preferences.
No endocarditis prophylaxis is indicated for patients with AS [3].
Adults with severe symptomatic AS should only engage in mild physical activity, as symptoms will be precipitated
by even moderate physical exertion.
Since patients with calcific aortic valve disease commonly have concurrent atherosclerotic disease, including
coronary artery disease, evaluation for and management of associated cardiovascular risk factors (eg,
hyperlipidemia) is recommended. (See "Medical management of asymptomatic aortic stenosis in adults", section
on 'Coronary artery disease' and "Secondary prevention of cardiovascular disease".)
At present, statin therapy solely to treat or prevent progression of AS (ie, in the absence of coexisting
atherosclerotic vascular disease or other indications) cannot be recommended. (See "Medical management of
asymptomatic aortic stenosis in adults", section on 'Prevention of disease progression'.)
Medical therapy for coronary artery disease, and atrial fibrillation should be continued in adults with AS, both in
those with and without symptoms. An appropriate goal for patients with atrial fibrillation is rate control with digoxin
and/or beta blockers. (See "Medical management of asymptomatic aortic stenosis in adults" and "Control of
ventricular rate in atrial fibrillation: Pharmacologic therapy".)
Management of loading conditions and symptoms
Even in the absence of an acute illness, adults with severe symptomatic inoperable AS may have fewer symptoms
and less frequent hospitalizations if loading conditions can be optimized. This includes treatment of hypertension
and maintaining a normal volume status.
Treatment of hypertension in severe symptomatic AS is challenging. Concomitant hypertension and AS present a
double load for the left ventricle (LV), which may adversely affect ventricular function [4]. The combination of
hypertension and AS may lead to development of symptoms as an earlier stage of AS [5]. However, no specific
treatment regimen for patients with AS with hypertension has been established.
Various medical therapies pose a risk of destabilizing the patient with AS:
Diuretics reduce preload, on which the patient may depend for maintenance of cardiac output. Therefore,
diuretics should be used with caution.

Despite these concerns, cautious treatment of hypertension starting with low doses and titrating slowly as needed
to optimize loading conditions is appropriate [6]. Angiotensin converting enzyme (ACE) inhibitors are used by some
[6]. Since experience in AS patients is limited, calcium channel blockers should be used with caution.
For management of patients who have had symptoms of heart failure, we suggest a combination of a diuretic and
an ACE inhibitor. These should be started at low doses with gradual titration.
Treatment is improved if patients are educated and involved in following daily weights and signs of decompensation.
In addition, patients should be educated about the effects of sodium intake, changes in elevation with travel, and
other factors that may lead to clinical decompensation. Frequent physician or nurse visits are needed for patient
monitoring.
Even with optimal care, adults with severe symptomatic inoperable AS will have exacerbations of symptoms and
frequent hospitalizations. Symptoms of dyspnea and chest pain are treated as described above, within the end-of-
life care parameters set by the patient. Dizziness and pre-syncope typically are exertional and can be avoided by
decreasing physical activity and instructing the patient to stop and sit (or lie) down when symptoms occur.
Palliative care includes symptomatic treatment for symptoms of dyspnea and angina. In addition, end-of-life
discussions and counseling are appropriate. (See "End of life considerations for heart failure patients".)
Prevention and treatment of concurrent conditions
Many adults with severe symptomatic AS have relatively stable symptoms with decompensation triggered by an
intercurrent illness such as influenza, anemia, pulmonary embolism, etc. Optimal preventative care can prevent
recurrent hospitalizations. These measures include pneumococcal vaccination, annual influenza vaccination, routine
preventative care examinations, and treatment of any noncardiac conditions.
When clinical decompensation occurs, in addition to treating the disease process, patients may be effectively
managed by supportive care during the acute illness. Medical therapy focuses on decreasing cardiac workload by
reducing fever, controlling heart rate and blood pressure, correction of anemia, and administration of oxygen.
Volume status should be carefully monitored with cautious replacement of fluid or gentle diuresis, as needed. With
severe AS, patients are very sensitive to small changes in preload, often called a "narrow preload window." An
increase in LV volume in a stiff hypertrophied LV results in a rapid rise in diastolic pressure and symptoms of
pulmonary congestion. Conversely, when filling volumes are too low, the small LV does not fill adequately with a fall
in forward stroke volume and signs of low output failure.
Medical management in patients awaiting aortic valve replacement In general, medical intervention prior
to AVR should be minimized in patients with severe or symptomatic AS. Most medical interventions carry the risk
of destabilizing the patient:
Critically ill patients awaiting valve replacement
Beta blockers reduce contractility, which may pose a risk for the overloaded LV. While low dose beta
blockers may be considered in patients with asymptomatic hypertension (particularly in the setting of atrial
fibrillation), beta blockers should be avoided in patients with symptomatic AS and heart failure.

Vasodilators (such as hydralazine, nitroglycerin, and nifedipine) in the presence of a fixed valvular stenosis
may reduce systemic blood pressure and reduce coronary artery perfusion pressure. These agents should be
avoided or used with caution. (See 'Critically ill patients awaiting valve replacement' below.)

Diuretics reduce preload, on which the patient may depend for maintenance of cardiac output.
Vasodilators in the presence of a fixed valvular stenosis may reduce systemic blood pressure and reduce
coronary artery perfusion pressure.

Positive inotropic agents such as dobutamine must be used with caution; tachycardia (with reduced cardiac
output) and myocardial ischemia (due to increased oxygen demand) may occur.

Some critically ill patients with AS are hemodynamically unstable prior to surgery and at high risk for mortality
during the procedure. This is especially true in patients with LV dysfunction, who may present with heart failure,
and those with coronary disease, who may present with unstable angina. It would be desirable to stabilize such
patients prior to surgery, but these are precisely the patients at highest risk of further decompensation with
injudicious medical intervention.
Percutaneous balloon valvotomy may reduce the aortic valve gradient and can potentially improve symptoms prior to
AVR. However, this procedure is associated with high morbidity and only transient efficacy. This was illustrated by
a series of 21 patients with AS and cardiogenic shock who underwent balloon valvotomy [7]. After the procedure,
there were significant increases in mean aortic pressure (from 77 to 116 mmHg), aortic valve area (from 0.48 to 0.84
cm ), and the cardiac index (from 1.84 to 2.24). However, nine of the patients died in the hospital during or after the
procedure. In addition, vascular complications occurred in five patients, and stroke, cholesterol emboli, and aortic
regurgitation occurred in one patient each.
Because of these limitations, balloon valvotomy should be considered only in selected clinical settings. (See
'Possible indications for aortic valvotomy' below.)
Although data are limited, nitroprusside may be useful in improving ventricular performance prior to surgery in an
attempt to reduce surgical risk. The use of nitroprusside was evaluated in a study of 25 patients with severe AS and
depressed LV function who were not hypotensive; nitroprusside was administered during continuous hemodynamic
monitoring with a pulmonary artery catheter [8]. During nitroprusside treatment, there were significant increases in
cardiac index (1.60 to 2.52 L/min per m ) and stroke volume (from 32 to 54 mL) and significant reduction in mean
arterial pressure (81 to 69 mmHg) and systemic vascular resistance. Five patients died in the hospital and 13
underwent successful AVR.
Although no complications occurred, the use of vasodilator therapy in such patients is associated with a risk of
hypotension and hemodynamic collapse, and it is unclear from this uncontrolled study whether the surgical
outcomes were improved [9]. This approach should be undertaken only with careful hemodynamic monitoring by
experienced clinicians.
A potential alternative approach is use of dobutamine in such patients, although use of nitroprusside or dobutamine
in critically ill patients with AS requires intensive monitoring.
POSSIBLE INDICATIONS FOR AORTIC VALVOTOMY Percutaneous aortic balloon valvotomy is a procedure in
which one or more balloons are placed across the stenotic aortic valve and inflated [10]. The aim is to relieve the
stenosis, presumably by fracturing calcific deposits within the valve leaflets. Stretching of the annulus and
separation of the calcified commissures also may contribute. Early changes after successful valvotomy include a
moderate reduction in the transvalvular pressure gradient and an often dramatic improvement in symptoms;
however, the postprocedure valve area rarely exceeds 1.0 cm [10,11].
Serious complications (stroke, aortic regurgitation, myocardial infarction) occur in approximately 10 to 20 percent of
patients [10-12]. Furthermore, restenosis and clinical deterioration occur in most cases within 6 to 12 months and
the long-term outcome resembles the natural history of untreated AS [11,13]. Repeat balloon valvotomy can be
performed, but most patients fail within six months [14].
Based upon these observations, the 2006 American College of Cardiology/American Heart Association (ACC/AHA)
guidelines concluded that balloon valvotomy is NOT a substitute for valve replacement in adults, although selected
young adults without valve calcification may represent an exception [3]. In addition, balloon valvotomy is frequently
used in children with valvar aortic stenosis (AS). (See "Valvar aortic stenosis in children", section on 'Balloon
valvotomy' and "Management of adults with bicuspid aortic valve disease", section on 'Role of balloon valvotomy'.)
Although the evidence is not well established, the guidelines noted two specific settings in adults in which balloon
valvotomy might be reasonable [3]:
2
2
2
As a bridge to transcatheter or surgical aortic valve replacement (AVR) in hemodynamically unstable patients
In addition, there are two other settings in which balloon valvotomy has been considered:
ROLE OF PALLIATIVE CARE Given the life-limiting nature of severe aortic stenosis (AS), as well as the high
symptom burden associated with severe AS, palliative care consultation is valuable in this population, particularly if
the AS is associated with other significant morbidities and/or if the patient is not a candidate for surgical or
transcatheter aortic valve replacement (TAVR).
Palliative care focuses on quality of life in people with life-limiting conditions, is provided alongside rather than
instead of active medical therapy, and is ideally not delayed until end stages of illness. It can and does include end-
of-life planning and care, but is meant to be initiated earlier in the course of illness. Palliative care is partly founded
on the principles of shared decision making, and its practitioners are highly skilled at ascertaining patients views
and preferences and helping the patients and family understand how various medical options will or will not facilitate
the patient in reaching their goals of care. (See "Palliative care: Benefits, services, and models of care".)
The principles outlined in reviews and position papers on palliative care and decision making in advanced heart
failure apply as well to patients with severe AS who have concomitant heart failure, who are elderly and frail, or who
have other chronic conditions that may limit their prognosis with or without surgical or percutaneous valve
replacement [17-19]. (See "End of life considerations for heart failure patients".)
In particular, patients for whom TAVR is being considered could benefit from consultation with palliative care
providers with advanced communication skills to promote shared decision making. These providers can facilitate
ascertainment of patients goals and preferences, assess patient knowledge and understanding of their disease,
and discuss prognosis and foreseeable outcomes with medical options. In many of these patients, TAVR will either
not be advisable, or the patients themselves will decide against it as being unlikely to help them achieve their goals.
For example, if the patients goals are to improve cognitive function, mobility, and independence, TAVR may not
help significantly with these goals.
INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, The Basics and
Beyond the Basics. The Basics patient education pieces are written in plain language, at the 5 to 6 grade
reading level, and they answer the four or five key questions a patient might have about a given condition. These
articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the
Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the
10 to 12 grade reading level and are best for patients who want in-depth information and are comfortable with
some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these
topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on
patient info and the keyword(s) of interest.)
who are at high risk for AVR. However, mortality remains high in these patients [7]. (See 'Critically ill patients
awaiting valve replacement' above.)
Use for palliation in patients with serious comorbid conditions that prevent performance of AVR.
As a bridge to delivery to symptomatic pregnant women. Although there are case reports suggesting
success, balloon valvotomy can induce aortic regurgitation even in experienced hands, the postdilation
bicuspid aortic valve remains susceptible to infective endocarditis irrespective of its functional state, the
ascending aorta still harbors an abnormal media, and recurrent stenosis is common within 6 to 12 months.
(See "Pregnancy in women with a bicuspid aortic valve".)

In patients who require urgent noncardiac surgery. However, the ACC/AHA guidelines concluded that most
asymptomatic patients with severe AS can undergo urgent noncardiac surgery at relatively low risk with
careful intraoperative and postoperative management, including monitoring of anesthesia and careful attention
to fluid balance [3,15,16]. Balloon valvotomy was not recommended; AVR should be considered if preoperative
correction of AS is warranted [3]. (See "Noncardiac surgery in patients with aortic stenosis".)

th th
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Di scl osures: Catherine M Otto, MD Nothing to disclose. Stephanie Cooper, MD Nothing to disclose. William H Gaasch, MD Nothing
to disclose. Susan B Yeon, MD, JD, FACC Employee of UpToDate, Inc.
Contributor disclosures are reviewed f or conf licts of interest by the editorial group. When f ound, these are addressed by vetting through
a multi-level review process, and through requirements f or ref erences to be provided to support the content. Appropriately ref erenced
content is required of all authors and must conf orm to UpToDate standards of evidence.
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Topic 8130 Version 8.0
Disclosures
Basics topic (see "Patient information: Aortic stenosis (The Basics)")
Symptomatic aortic stenosis (AS) is an indication for aortic valve replacement (AVR) and medical therapy has
limited utility in treating symptoms. However, medical management may be required in patients who are not
candidates for surgery (either due to comorbid conditions or patient refusal to undergo valve replacement).
(See 'Settings' above.)

Palliative care for severe symptomatic inoperable AS includes the following (see 'Medical management'
above):

Treatment of concurrent cardiovascular conditions such as atrial fibrillation and coronary artery disease.
Management of loading conditions and symptoms. Careful treatment of hypertension is appropriate. For
patients with heart failure, we suggest a combination of a diuretic and an angiotensin converting enzyme
inhibitor. These should be started at low doses with gradual titration.

Prevention and treatment of concurrent conditions.

End-of-life discussions and counseling. (See 'Role of palliative care' above.)
In critically ill patients with severe AS, attempts to medically stabilize the patient should be undertaken with
caution. In these patients, we recommend prompt AVR. (See 'Critically ill patients awaiting valve replacement'
above.)