Aortic stenosis cardiac stress test

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Aysha Anwar, M.B.B.S[2]; Usama Talib, BSc, MD [3]

Overview

Exercise testing should not be performed in symptomatic patients with AS but can be used to elicit exercise-induced symptoms and abnormal blood pressure responses in asymptomatic patients.

Cardiac stress test

Cardiac stress testing may be used in patients with asymptomatic severe aortic stenosis for risk stratification. An early exercise test such as treadmill may be used. Patients developing symptoms and inadequate blood pressure change <20 mmHg may indicate severe aortic stenosis indicating surgery in such patients. Low dose dobutamine echocardiography may also be used in patients with decreased contractile reserves to stratify the patients as high risk and hence to determine the need for surgery.

2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

Recommendations for Diagnostic Testing: Initial Diagnosis of AS Referenced studies that support the recommendations are summarized in the Online Data Supplement

Class I

1.    In patients with signs or symptoms of AS or a BAV, TTE is indicated for accurate diagnosis of the cause of AS, assessment of hemodynamic severity, measurement of LV size and systolic function, and determination of prognosis and timing of valve intervention(Level of Evidence: A) 2.   In patients with suspected low-flow, low-gradient severe AS with normal LVEF (Stage D3), optimization of blood pressure control is recommended before measurement of AS severity by TTE, TEE, cardiac catheterization, or CMR(Level of Evidence: B-NR)

Class IIa

3.   In patients with suspected low-flow, low-gradient severe AS with reduced LVEF (Stage D2), low-dose dobutamine stress testing with echocardiographic or invasive hemodynamic measurements is reasonable to further define severity and assess contractile reserve(Level of Evidence: B-NR) 4.   In patients with suspected low-flow, low-gradient severe AS with normal or reduced LVEF (Stages D2 and D3), calculation of the ratio of the outflow tract to aortic velocity is reasonable to further define severity(Level of Evidence: B-NR) 5.   In patients with suspected low-flow, low-gradient severe AS with normal or reduced LVEF (Stages D2 and D3), measurement of aortic valve calcium score by CT imaging is reasonable to further define severity(Level of Evidence: B-NR)

2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Diseases (DO NOT EDIT)

Diagnosis and Follow-Up

Class IIa

"1. Low-dose dobutamine stress testing using echocardiographic or invasive hemodynamic measurements is reasonable in patients with stage D2 AS with all of the following: a. Calcified aortic valve with reduced systolic opening; b. LVEF less than 50%; c. Calculated valve area 1.0 cm2 or less; and d. Aortic velocity less than 4.0 m per second or mean pressure gradient less than 40 mm Hg. (Level of Evidence: B)"

"2. Exercise testing is reasonable to assess physiological changes with exercise and to confirm the absence of symptoms in asymptomatic patients with a calcified aortic valve and an aortic velocity 4.0 m per second or greater or mean pressure gradient 40 mm Hg or higher. (Level of Evidence: C)"

Class III: Harm

"1. Exercise testing should not be performed in symptomatic patients with AS when the aortic velocity is 4.0 m per second or greater or mean pressure gradient is 40 mm Hg or higher (stage D). (Level of Evidence: B)"

2008 and Incorporated 2006 ACC/AHA Guidelines for the Management of Patients with Valvular Heart Disease (DO NOT EDIT)

Cardiac Stress Test (DO NOT EDIT)

Class III

"1. Exercise testing should not be performed in symptomatic patients with AS. (Level of Evidence: B)"

Class IIb

"1. Exercise testing in asymptomatic patients with AS may be considered to elicit exercise-induced symptoms and abnormal blood pressure responses. (Level of Evidence: B)"

Asymptomatic Adolescents (DO NOT EDIT)

Class IIa

"1. Graded exercise testing is a reasonable diagnostic evaluation in the adolescent or young adult with AS who has a Doppler mean gradient greater than 30 mm Hg or a peak velocity greater than 3.5 m per second (peak gradient greater than 50 mm Hg) if the patient is interested in athletic participation, or if the clinical findings and Doppler findings are disparate. (Level of Evidence: C)"