Skip to main content
NCBI home page
Heart logoLink to Heart
. 2001 Oct;86(4):381–386. doi: 10.1136/heart.86.4.381

Treatment decision in asymptomatic aortic valve stenosis: role of exercise testing

M Amato 1, P Moffa 1, K Werner 1, J Ramires 1
PMCID: PMC1729928  PMID: 11559673

Abstract

OBJECTIVE—To determine the prognostic value of exercise testing, valve area, and maximum transaortic pressure gradient in asymptomatic patients with aortic valve stenosis.
SETTING—The outpatient service of a tertiary referral centre for cardiology.
DESIGN—Prospective clinical study.
PATIENTS—66 consecutive patients with isolated severe aortic stenosis (aortic valve area ⩽ 1.0 cm2) were selected over a 58 month period. Mean (SD) follow up was 14.77 (11.93) months.
INTERVENTIONS—At the initial visit Doppler echocardiography and exercise testing were performed to evaluate ST segment depression and the development of symptoms of aortic stenosis, ventricular arrhythmia, or inadequate rise of systolic blood pressure during exercise. Follow up clinical examinations were performed every three months thereafter to record the onset of symptoms.
MAIN OUTCOME MEASURES—Sudden death or the development of symptoms.
RESULTS—Eight patients developed dizziness during exercise testing but made a rapid and spontaneous recovery. No other complications of exercise testing occurred. Survival curves, with or without the occurrence of end point events for the variables studied, showed significant differences for positive versus negative exercise testing (p = 0.0001) and aortic valve area < 0.7 cm2 v ⩾ 0.7 cm2 (p = 0.0021). There was no relation between the end points and transaortic gradient (p = 0.6882). In multivariate analysis, a hazard ratio of 7.43 was calculated for patients with a positive versus a negative exercise stress test. Although asymptomatic in daily life, 6% of the patients (4/66) experienced sudden death; all these had a positive exercise test and an aortic valve area of ⩽ 0.6 cm2.
CONCLUSIONS—Exercise testing is safe and is of prognostic value in asymptomatic patients with aortic stenosis.


Keywords: aortic valve stenosis; exercise testing; Doppler echocardiography

Full Text

The Full Text of this article is available as a PDF (151.9 KB).

Figure 1  .

Figure 1  

Open in a new tab

Kaplan-Meier life table analysis for probability of event-free survival over 60 months for patients with asymptomatic severe aortic stenosis, according to maximum transaortic pressure gradient ⩽ 70 mm Hg or > 70 mm Hg.

Figure 2  .

Figure 2  

Open in a new tab

Kaplan-Meier life table analysis for probability of event-free survival over 60 months for patients with asymptomatic severe aortic stenosis, according to aortic valve area < 0.7 cm2 or ⩾ 0.7 cm2.

Figure 3  .

Figure 3  

Open in a new tab

Kaplan-Meier life table analysis for probability of event-free survival over 60 months for patients with asymptomatic severe aortic stenosis, according to positive or negative results of exercise testing.

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. ACC/AHA guidelines for the management of patients with valvular heart disease. A report of the American College of Cardiology/American Heart Association. Task Force on Practice Guidelines (Committee on Management of Patients with Valvular Heart Disease). J Am Coll Cardiol. 1998 Nov;32(5):1486–1588. doi: 10.1016/s0735-1097(98)00454-9. [DOI] [PubMed] [Google Scholar]
  2. Amato M. C., Pomerantzeff P., Grinberg M., Bellotti G., Pileggi F. Evoluço imediata e tardia de pacientes com bioprótese porcina. Arq Bras Cardiol. 1988 Nov;51(5):381–384. [PubMed] [Google Scholar]
  3. Amato M. C., Pommerantzeff P., Grinberg M., Stolf N., Verginelli G., Pileggi F., Jatene A. Implante de prótese de Starr Edwards há mais de 15 anos. Análise de 34 casos. Arq Bras Cardiol. 1987 May;48(5):299–301. [PubMed] [Google Scholar]
  4. Archer S. L., Mike D. K., Hetland M. B., Kostamo K. L., Shafer R. B., Chesler E. Usefulness of mean aortic valve gradient and left ventricular diastolic filling pattern for distinguishing symptomatic from asymptomatic patients. Am J Cardiol. 1994 Feb 1;73(4):275–281. doi: 10.1016/0002-9149(94)90233-x. [DOI] [PubMed] [Google Scholar]
  5. Braunwald E. On the natural history of severe aortic stenosis. J Am Coll Cardiol. 1990 Apr;15(5):1018–1020. doi: 10.1016/0735-1097(90)90235-h. [DOI] [PubMed] [Google Scholar]
  6. Frank S., Johnson A., Ross J., Jr Natural history of valvular aortic stenosis. Br Heart J. 1973 Jan;35(1):41–46. doi: 10.1136/hrt.35.1.41. [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Freeman W. K., Schaff H. V., Orszulak T. A., Tajik A. J. Ultrasonic aortic valve decalcification: serial Doppler echocardiographic follow-up. J Am Coll Cardiol. 1990 Sep;16(3):623–630. doi: 10.1016/0735-1097(90)90352-p. [DOI] [PubMed] [Google Scholar]
  8. Gibbons R. J., Balady G. J., Beasley J. W., Bricker J. T., Duvernoy W. F., Froelicher V. F., Mark D. B., Marwick T. H., McCallister B. D., Thompson P. D., Jr ACC/AHA Guidelines for Exercise Testing. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing). J Am Coll Cardiol. 1997 Jul;30(1):260–311. doi: 10.1016/s0735-1097(97)00150-2. [DOI] [PubMed] [Google Scholar]
  9. Gould K. L. Why angina pectoris in aortic stenosis. Circulation. 1997 Feb 18;95(4):790–792. doi: 10.1161/01.cir.95.4.790. [DOI] [PubMed] [Google Scholar]
  10. Grech E. D., Ramsdale D. R. Exertional syncope in aortic stenosis: evidence to support inappropriate left ventricular baroreceptor response. Am Heart J. 1991 Feb;121(2 Pt 1):603–606. doi: 10.1016/0002-8703(91)90737-3. [DOI] [PubMed] [Google Scholar]
  11. Horstkotte D., Loogen F. The natural history of aortic valve stenosis. Eur Heart J. 1988 Apr;9 (Suppl E):57–64. doi: 10.1093/eurheartj/9.suppl_e.57. [DOI] [PubMed] [Google Scholar]
  12. Iivanainen A. M., Lindroos M., Tilvis R., Heikkilä J., Kupari M. Natural history of aortic valve stenosis of varying severity in the elderly. Am J Cardiol. 1996 Jul 1;78(1):97–101. doi: 10.1016/s0002-9149(96)00235-4. [DOI] [PubMed] [Google Scholar]
  13. Johnson A. M. Aortic stenosis, sudden death, and the left ventricular baroceptors. Br Heart J. 1971 Jan;33(1):1–5. doi: 10.1136/hrt.33.1.1. [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Kelly T. A., Rothbart R. M., Cooper C. M., Kaiser D. L., Smucker M. L., Gibson R. S. Comparison of outcome of asymptomatic to symptomatic patients older than 20 years of age with valvular aortic stenosis. Am J Cardiol. 1988 Jan 1;61(1):123–130. doi: 10.1016/0002-9149(88)91317-3. [DOI] [PubMed] [Google Scholar]
  15. Nitta M., Nakamura T., Hultgren H. N., Bilisoly J., Tovey D. A. Progression of aortic stenosis in adult men. Detection by noninvasive methods. Chest. 1987 Jul;92(1):40–43. doi: 10.1378/chest.92.1.40. [DOI] [PubMed] [Google Scholar]
  16. OLESEN K. H., WARBURG E. Isolated aortic stenosis; the late prognosis. Acta Med Scand. 1958 May 6;160(6):437–446. doi: 10.1111/j.0954-6820.1958.tb10368.x. [DOI] [PubMed] [Google Scholar]
  17. Otto C. M. Aortic stenosis. Clinical evaluation and optimal timing of surgery. Cardiol Clin. 1998 Aug;16(3):353-73, vii. doi: 10.1016/s0733-8651(05)70020-5. [DOI] [PubMed] [Google Scholar]
  18. Otto C. M., Burwash I. G., Legget M. E., Munt B. I., Fujioka M., Healy N. L., Kraft C. D., Miyake-Hull C. Y., Schwaegler R. G. Prospective study of asymptomatic valvular aortic stenosis. Clinical, echocardiographic, and exercise predictors of outcome. Circulation. 1997 May 6;95(9):2262–2270. doi: 10.1161/01.cir.95.9.2262. [DOI] [PubMed] [Google Scholar]
  19. Otto C. M., Pearlman A. S., Kraft C. D., Miyake-Hull C. Y., Burwash I. G., Gardner C. J. Physiologic changes with maximal exercise in asymptomatic valvular aortic stenosis assessed by Doppler echocardiography. J Am Coll Cardiol. 1992 Nov 1;20(5):1160–1167. doi: 10.1016/0735-1097(92)90373-u. [DOI] [PubMed] [Google Scholar]
  20. Pellikka P. A., Nishimura R. A., Bailey K. R., Tajik A. J. The natural history of adults with asymptomatic, hemodynamically significant aortic stenosis. J Am Coll Cardiol. 1990 Apr;15(5):1012–1017. doi: 10.1016/0735-1097(90)90234-g. [DOI] [PubMed] [Google Scholar]
  21. Rapaport E. Natural history of aortic and mitral valve disease. Am J Cardiol. 1975 Feb;35(2):221–227. doi: 10.1016/0002-9149(75)90005-3. [DOI] [PubMed] [Google Scholar]
  22. Richardson J. W., Anderson F. L., Tsagaris T. J. Rest and exercise hemodynamic studies in patients with isolated aortic stenosis. Cardiology. 1979;64(1):1–11. doi: 10.1159/000170573. [DOI] [PubMed] [Google Scholar]
  23. Ross J., Jr, Braunwald E. Aortic stenosis. Circulation. 1968 Jul;38(1 Suppl):61–67. doi: 10.1161/01.cir.38.1s5.v-61. [DOI] [PubMed] [Google Scholar]
  24. Turina J., Hess O., Sepulcri F., Krayenbuehl H. P. Spontaneous course of aortic valve disease. Eur Heart J. 1987 May;8(5):471–483. doi: 10.1093/oxfordjournals.eurheartj.a062307. [DOI] [PubMed] [Google Scholar]
  25. Vongpatanasin W., Hillis L. D., Lange R. A. Prosthetic heart valves. N Engl J Med. 1996 Aug 8;335(6):407–416. doi: 10.1056/NEJM199608083350607. [DOI] [PubMed] [Google Scholar]

Articles from Heart are provided here courtesy of BMJ Publishing Group

RESOURCES