question and answer
Aortic stenosis in the elderly
June 2011
What’s the best line of management for severe aortic stenosis in octogenarians with low ventricular function? Ahmed Ahmed MD, Halifax, NS

Cardiologist’s answer:

This is an evolving field. There’s now data showing that percutaneous valves can be put in place. Recently a RCT of just over 700 patients showed that valvular surgery and/or percutaneous valves led to a similar benefit at one year. The procedure is common in Europe, but here in North America it’s felt that we need more data before this becomes the standard practice. However, this is exciting and new technology that we need to keep a close eye on. There was a downside: stroke occurred in 8% of subjects in the percutaneous group vs 4% in the surgical arm. Unfortunately, close to one in four patients in both groups passed away within a year. Patients with LV dysfunction face an even higher risk and if the cause is related to aortic stenosis then surgery is probably the best option if the patient is otherwise a relatively “healthy 80-year-old.” But with advanced CAD and multiple MIs, diabetes, renal dysfunction, organic brain syndrome, medical therapy may be the best option. Again, many of these patients are very ill with multiple comorbidities. Clinical judgement is necessary.
Gregory P. Curnew, MD

Geriatrician’s answer:

Aortic stenosis is common, occurring in 2-9% of patients over the age of 65, and in 90% of the elderly it’s caused by calcification of a tricuspid aortic valve. Aortic stenosis needs to be distinguished from aortic sclerosis. The latter is not associated with a narrowing between the systolic and diastolic blood pressures, not accompanied by cardiomegaly or LVH on ECG and does not have the typical “pulsus parvus et tardus” that occurs in true aortic stenosis. Severe aortic stenosis is usually defined as an aortic valve area of less than 1 square cm. or a mean gradient across the valve of greater than 40 mm Hg.

As for management, patients regardless of age should be considered for valve replacement once they develop symptoms such as syncope, angina or dyspnea. Age alone isn’t a contraindication to surgery and there are many studies demonstrating favourable outcomes even in quite elderly patients. But mortality is clearly increased in certain situations such as emergency surgery, or where ventricular function is badly impaired. If the elderly patient requires coronary bypass surgery, then concomitant aortic valve replacement should certainly be considered. If, on the other hand, surgery isn’t an option because of palliation, comorbidities, etc., then the mainstay of management includes diuretics e.g. furosemide to control heart failure, and antihypertensive management.

ACE inhibitors have traditionally not been used for fear of decreasing coronary perfusion secondary to excessive afterload reduction. Current practice has no absolute contraindication to ACE inhibitors or ARBs, but they do need to be used cautiously and under supervision.
Joel Hurwitz, MD

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