Influence of atypical symptoms and electrocardiographic signs of left ventricular hypertrophy or ST-segment/T-wave abnormalities on the natural history of otherwise asymptomatic adults with moderate to severe aortic stenosis: preliminary communication.

Background And Aim Of The Study: Current guidelines recommend that aortic valve replacement (AVR) is deferred in asymptomatic patients with aortic stenosis until symptoms develop. Classical symptoms include exertional dyspnea, angina pectoris and syncope. The influence of atypical symptoms (dizziness, exertional intolerance, fatigue, palpitations/arrhythmias) and electrocardiographic signs of left ventricular hypertrophy or ST-segment/T-wave abnormalities on the natural course of the disease is unknown.

Methods: The clinical course of 100 patients with a preliminary diagnosis of asymptomatic aortic stenosis with respect to clinical signs and symptoms mentioned above was examined. All patients underwent serial echocardiographic examinations with calculation of aortic valve area by the continuity equation.

Results: Two patients died during a mean follow up period of 34 +/- 32 months (range: 1-116 months). There were no peri- or postoperative deaths. Seven patients with hemodynamically severe aortic stenosis and concomitant atrial fibrillation, four with classical symptoms after re-evaluation, and five with left ventricular dysfunction underwent short-term AVR and were excluded from any subsequent analysis. In total, 84 patients were either entirely asymptomatic (n = 57; group A) or had atypical symptoms (n = 27; group B). Of these patients, 18 underwent AVR before onset of classical symptoms for various reasons, and 21 were treated medically. The remaining 15 group B patients exhibited classical symptoms significantly earlier than the remaining 30 group A patients (15 +/- 7 versus 35 +/- 24 months; p < 0.002). Aortic valve area tended to decrease more rapidly in group B patients than in group A patients (-0.16 +/- 0.12 versus -0.11 +/- 0.07 cm2 per year; p = 0.053). Clinical and hemodynamic progression were further increased if additional electrocardiographic abnormalities were present.

Conclusion: Both atypical symptoms and electrocardiographic signs of left ventricular hypertrophy/strain shorten the time interval until otherwise asymptomatic patients exhibit classical symptoms of advanced aortic stenosis requiring prosthetic valve replacement.