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AorticStenosis2014AHA/ACCGuidelinefortheManagementofPatientsWithValvularHeartDiseaseDepartment1ofCardiovascularMedicine,GD2HChenWuqiAorticStenosis1.StagesofValularAS2.DiagnosesandFollow-Up3.MedicalTherapy4.TimingofIntervention5.ChoiceofIntervention1.StagesofValularAS1.1.4StagesstageA:riskofASstageB:progressiveASstageC:asymptomaticsevereASstageD:symptomaticsevereAS1.StagesofValularAS1.2.Definesby4factora.valveanatomycalcification,reducedleafletopeningb.valvehemodynamicspeakaorticvalvevelocity,meanaorticvalvegradientc.hemodynamicconsequenceshemodynamicconsequencesLVdiastolicdysfunsion,LVhypertrophy,LVEFdescrease,LVchamberd.patientsymptomsexertionaldyspnea,angina,heartfailure,syncope2.DiagnosisandFollow-Up2.1InitialDiagnosisTTE(transthoracicechocardiography)Low-dosedobutaminestresstesting2.2ChangingSignsorSymptoms2.3RoutineFollow-Up2.4CardiacCatheterization2.5ExerciseTesting2.DiagnosisandFollow-Up2.1InitialDiagnosis2.1.1TTE(ClassI,B)concernbicuspidaorticvalve,cause,LVsize,systolicfunction,maximumtransvalvularvelocity,meanpressuregradient,continuityequationvalveareatiminganunexplainedsystolicmurmur,asinglesecondheartsound,ahistoryofabicuspidaorticvalve,symptomsthatmightbeduetoAS2.DiagnosisandFollow-Up2.1InitialDiagnosis2.1.2Low-dosedobutaminestresstesting(ClassI,B)inpatientswithstagesD2AS:a.Calcifiedaorticvalvewithreducedsystolicopening;b.LVEFlessthan50%;c.Calculatedvalvearea1.0cm2orless;andd.Aorticvelocitylessthan4.0mpersecondormeanpressuregradientlessthan40mmHg.2.DiagnosisandFollow-Up2.1InitialDiagnosis2.1.2Low-dosedobutaminestresstesting(ClassI,B):a.beginningat5mcg/kgperminuteb.increasinginincrementsof5mcg/kgperminutec.maximumdoseof20mcg/kgperminuteDefinitionofsevereASamaximumvelocity>4.0m/swithavalvearea≤1.0cm2trueseverASprogressiveAS3thgroupaorticvelocity≥4.0m/s<4.0m/s<4.0m/smeanpressuregradient≥40mmHg<40mmHg<40mmHgvalvearea≤1.0cm2>1.0cm2<1.0cm2LVEFincrease>20%>20%<20%2.DiagnosisandFollow-Up2.2ChangingSignsorSymptomsloudersystolicmurmurchangeinthesecondheartsoundsymptomsoccurthatmightbeduetoASnoncardiacsurgeryrepeatTTEpregnancyanemiagastrointestinalbleeding2.DiagnosisandFollow-Up2.3RoutineFollow-UpStagevmax(m/s)developintervalsB2-2.910%/5y3-5y3-3.90.3m/s/y1-2yC≥450-70%/2y0.5-1y2.DiagnosisandFollow-Up2.4CardiacCatheterizationnoninvasivedatanondiagnostic/discrepancyconcerntransaorticpressuregradientsaorticvalveareacoronaryangiography2.DiagnosisandFollow-Up2.5ExerciseTestingStageC(ClassII,B)a.asymptomaticpatientsb.acalcifiedaorticvalvec.aorticvelocity≥4.0m/sd.meanpressuregradient≥40mmHgStageD(ClassIII,B)2.DiagnosisandFollow-Up2.5ExerciseTestingpositivetestingresultsin29%ofasymptomaticpatients51%ofthemdevelopedsymptomsoverthenextyearpositive:stageCstageD1concernsymptomslimitedexercisecapacityabnormalBPresponse(hypotensionor<20mmHgincrease)arrhythmiaST-segmentdepression(>80%ofpatientswithAS)3.MedicalTherapy3.1Antihypertension(ClassI,B)hypertensioninstageA,stageB,stageCreducesthetotalpressureoverloadattentionstandardGDMT(guideline-diretedmedicaltherapy)startedatalowdose,graduallytitratedupwardfrequentclinicalmonitoring(symptoms)nospecificindicationdiureticsshouldbeavoidediftheLVchamberissmallBetaMockersareappropriateinpatientswithconcurrentCAD.3.MedicalTherapy3.2Vasodilatortherapy(ClassIIb,C)severeASandNYHAclassIVHFInvasivemonitoring:LVfillingpressures,cardiacoutput,s...