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Can we reduce the burden of aortic stenosis? Bench to Bedside Symposium

Prof. H. Boudoulas
Athens, Greece

Pathogenetic mechanisms

The incidence of calcific aortic stenosis increases with age. Thus, as life expectancy increases, it is expected that the frequency of aortic stenosis will also increase. Data suggest, however, that calcific aortic stenosis is not related only to ageing, but it is an active process. Studies indicate that aortic stenosis is inflammatory process with leucocytes and macrophages activation and infiltration. Serum inflammatory markers such as the C-reactive protein (CRP) and others are elevated in pts with aortic stenosis. In addition, autoimmune phenomena are also involved. Although the precise pathophysiologic mechanisms are not well understood, it is known that genetic and environmental factors are responsible for the development and progression of aortic stenosis.

Medical management

Data suggest that cardiovascular risk factors responsible for the development and progression of coronary atherosclerosis are responsible for the progression of aortic stenosis. It follows that aggressive management of these factors, especially smoking cessation, cholesterol reduction, blood pressure control, may slow the progression of AS. Data from small studies indicate that therapy with statins slows the progression of AS. Several large prospective randomized studies, which are presently in progress, will provide more information related to cholesterol reduction and natural history of AS, and also will answer the question whether inhibition of angiotensin will have a protective effect.

Sudden death

Certain patients with severe AS will die suddenly. It is well appreciated today, however, that sudden death occurs almost exclusively in symptomatic patients with AS. Thus, at present in asymptomatic patients with AS, aortic valve replacement is not indicated to prevent sudden death. It should be emphasized however, that careful history it is essential to evaluate for symptoms, in relation to patients’ activities, and importantly, to assess if the patient has gradually decreased his physical activities over the last several months to avoid symptoms. Exercise stress test can be performed safely, with great care, to evaluate patients’ symptoms; it is not routinely indicated, however.

The take-home message is that aortic stenosis is an active inflammatory process. Risk factors similar to those related to coronary atherosclerosis are involved in the progression of the disease. It follows therefore, that progression of the disease can be significantly decreased with aggressive control of those risk factors (cholesterol reduction, smoking cessation etc). Surgery is not indicated in asymptomatic patients with AS to prevent sudden death, regardless of the severity of the disease.

Autor: Prof. H. Boudoulas

Fuente: European Society of Cardiology

Ultima actualizacion:2 DE OCTUBRE DE 2004

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