Navigating the silence: reconsidering treatment paradigms in asymptomatic severe aortic stenosis

Aortic stenosis (AS) remains the leading valvular heart disease worldwide, affecting up to 5% of older adults and posing a significant risk if left untreated. The evolution of transcatheter aortic valve replacement (TAVR) and its expanding indications for symptomatic patients with severe AS, coupled with the evolving understanding of the pathophysiology and natural history of AS, have heightened the focus on asymptomatic patients with severe AS. Although current clinical practice guidelines recommend aortic valve replacement (AVR) therapy in asymptomatic severe aortic stenosis (ASAS) only in specific clinical settings, recent studies have challenged traditional treatment paradigms, advocating for a more individualized strategy, particularly for patients exhibiting high-risk characteristics. In this review, we provide an in-depth analysis of ASAS, focusing on the intricacies of its clinical management, novel risk-stratification modalities, and predictors of symptom onset and disease progression. We also determine the role of echocardiography in assessing AS severity, highlighting inconsistencies in diagnostic criteria and the need for supplementary testing. Evolving and recently published randomized controlled trials-namely EARLY-TAVR, EVoLVeD, and TAVR-UNLOAD-randomizing asymptomatic patients to early intervention or a watchful waiting strategy provide significant evidence that has the potential to change treatment paradigms, lower the threshold for intervention, and pave the way for more individualized management strategies in ASAS.