The role of stress testing in evaluation of asymptomatic patients with aortic stenosis

The emerging role of exercise and especially exercise echocardiography in aortic stenosis has been recently emphasized. In this clinical setting, stress testing can help identify patients who are falsely asymptomatic, unmask those who will rapidly become symptomatic and appraise the true haemodynamic consequences of aortic stenosis.

Both exercise stress test and exercise stress echocardiography are strictly contraindicated in symptomatic patients. In contrast, exercise testing is recommended by current guidelines in asymptomatic patients with aortic stenosis. During exercise, either the development of symptoms or an abnormal blood pressure response is associated with a poor outcome and should be considered as an indication for surgery. Exercise echocardiography permits stratification and identification of asymptomatic patients at a higher risk of a cardiac event: exercise-induced increase of more than 18-20  mmHg in mean pressure gradient, absence of left ventricular contractile reserve and/or exercise pulmonary hypertension are suggestive features of an advanced disease process.

Exercise echocardiography has the advantage of its wide availability, low cost and versatility. In asymptomatic severe aortic stenosis, exercise echocardiography can help unmask patients at a more advanced stage of the disease and could aid in identifying those who may benefit from an early elective aortic valve surgery.