As we know, aortic stenosis (AS) is the most common valvular heart disease in our setting. Over recent decades, numerous studies have been published and major advances have been made in the diagnosis and treatment of this condition, leading to improved survival, a lower incidence of heart failure (HF) symptoms, and better quality of life for our patients. Despite these advances, the main determinant for invasive treatment of this valvular disease has remained the development of symptoms. However, the recently published 2025 ESC clinical practice guidelines, supported by data from randomized trials, now advocate earlier intervention in broad groups of asymptomatic patients, including those with left ventricular ejection fraction (LVEF) <50% without another cause of dysfunction, those with high gradients and LVEF >50% when procedural risk is low, those with very severe AS, very severe valve calcification, marked elevation of natriuretic peptides, or simply LVEF <55% without another associated cause. Traditionally, the symptom-free phase had been regarded as benign, but growing recognition of structural damage affecting both the left ventricle and other cardiac chambers secondary to AS has changed that view. In parallel, improvements in both surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR) have reduced the morbidity and mortality associated with these procedures.

The authors of this article review a meta-analysis evaluating 4 randomized clinical trials comparing close clinical surveillance with valve replacement (SAVR or TAVR), whose results and characteristics of the included studies we had already discussed previously on this blog. Based on that meta-analysis, they propose a series of measures to implement proactive management in clinical practice. The first would be early referral of patients with severe AS, or with discordant findings suggestive of severe AS, to specialized valve units. These multidisciplinary units, composed of different professionals including cardiologists specialized in valvular heart disease and cardiac imaging, interventional cardiologists, and cardiac surgeons, would complete the diagnostic work-up, assess patient comorbidities, identify the individual risks of each procedure, and determine treatment strategy and planning, always within a framework of communication and shared decision-making with the patient and family. To do so, they would rely on basic diagnostic tools such as transthoracic echocardiography (TTE) and cardiac computed tomography (CT), but also on other tests such as dobutamine stress echocardiography (DSE) in uncertain cases, particularly low-flow, low-gradient AS, or treadmill exercise testing to assess risk in patients declining intervention, together with measurement of natriuretic peptides and frailty assessment. On that basis, they propose a treatment timing strategy according to symptoms and complementary test findings. In symptomatic patients, the ideal treatment window would be less than 1 month, and preferably within 2 weeks of diagnosis, whereas in asymptomatic patients the maximum interval would be 3 months. For patients declining intervention, they propose proactive follow-up including exercise testing, serial echocardiograms, natriuretic peptide assessment, and close surveillance through monthly telephone contact and face-to-face visits every 3 months.

The authors themselves offer a critical appraisal of their own proposal, acknowledging that this new management paradigm raises several important issues. The first is the loss of autonomy for the general cardiologist or the patient’s primary cardiologist, because under this model they would neither complete the diagnostic evaluation nor participate in decision-making. They also recognize that referrals to valve units would increase substantially, with the risk of overwhelming these structures, and they consider the possible supportive role of expert clinical cardiologists. Likewise, they acknowledge concerns about prosthesis durability, both surgical and transcatheter, if intervention is brought forward, which would likely increase the number of future reinterventions. Finally, they point to the highly probable hospital and economic burden associated with this paradigm shift.

COMMENTARY:

This article, authored by a group of specialists with the highest level of authority in aortic stenosis, addresses how to implement the paradigm shift in the management of asymptomatic patients recommended in the latest ESC clinical practice guidelines. It proposes a scheme of early referral of patients with clinical suspicion of severe AS to a dedicated valve unit, where the diagnostic evaluation would be completed and decision-making streamlined by highly specialized professionals. The authors advocate this model over the current strategy of close surveillance, in which delays may occur in the performance of diagnostic testing, in decision-making, and in waiting lists for valve replacement, with unpredictable morbidity and mortality during that period. By concentrating the entire process within the valve unit, these delays could be shortened and patient morbidity and mortality consequently reduced.

The article is intended as a practical guide, although it raises a number of issues that are difficult to implement in daily practice. First, multidisciplinary valve units are far from universally available, because in many centers patient follow-up and interpretation of diagnostic testing are still performed by the general cardiologist, while therapeutic decisions are made during specific multidisciplinary meetings. In this article, the role of the general cardiologist appears to be reduced to that of a mere referrer to the valve unit, which may suggest a certain underestimation of their capabilities. On the other hand, current waiting lists for diagnostic testing, which are already prolonged even in symptomatic patients, could become even longer if the number of investigations increases in asymptomatic individuals. The same would apply to waiting lists for intervention, whether surgical or transcatheter. This seems difficult to solve unless separate waiting lists were created for symptomatic and asymptomatic patients, which could generate a substantial administrative and economic burden and would still require very close follow-up of asymptomatic patients who develop clinical changes. Finally, the closing acknowledgment to one of the main manufacturers of valve prostheses, both transcatheter and surgical, for providing logistical and administrative support to the authors during preparation of the article is striking, and it inevitably raises some concern about potential bias.

The management of patients with severe aortic stenosis, whether symptomatic or asymptomatic, requires a complex and standardized multidisciplinary approach, which will represent a challenge for healthcare systems and a major shift in routine clinical practice.

REFERENCE:

Cook CM, Pibarot P, Tarantini G, Généreux P, Delgado V, et al. Proactive Management and Treatment of Aortic Stenosis: An International Expert Perspective. J Am Coll Cardiol. 2026 Feb 3;87(4):414-438. doi: 10.1016/j.jacc.2025.10.074.