Management of severe asymptomatic aortic stenosis: An updated overview

Aortic stenosis is the most frequent valvular heart disease in industrialized countries, affecting about 10% of individuals aged>75years, with 2-4% presenting severe disease; nearly half of them are asymptomatic. No medical therapy halts aortic stenosis progression, and aortic valve replacement remains the only curative option. Managing asymptomatic patients is challenging because of a persistent risk of sudden death, and the potential for irreversible myocardial damage if intervention is delayed, but also because aortic valve replacement carries procedural risks and long-term prosthesis-related complications. Functional assessment, especially exercise testing, is essential as it can identify a substantial proportion of "falsely asymptomatic" patients who will benefit from timely aortic valve replacement. Accurate assessment of aortic stenosis severity is crucial, with echocardiography as the cornerstone, although additional imaging modalities may be required in selected cases. Modern risk stratification integrates markers of subclinical myocardial dysfunction, haemodynamic compromise and procedural risk. Although observational studies and randomized trials suggest that early aortic valve replacement may reduce adverse events in selected low-risk patients, results are heterogeneous and methodological concerns remain. Meta-analyses have shown reductions in unplanned hospitalizations but no clear survival benefit with early intervention. Current guidelines recommend aortic valve replacement for classical indications, such as symptom onset or reduced ejection fraction, and suggest early aortic valve replacement only in carefully selected asymptomatic patients with low procedural risk. Shared decision-making within a multidisciplinary heart valve team remains essential, taking into account patient preferences, co-morbidities, life expectancy and lifestyle. Close follow-up with regular echocardiography and functional testing is critical to optimize timing and outcomes.