Patient screening for early detection of aortic stenosis (AS)—review of current practice and future perspectives

The burden of heart valve disease (VHD) is rising due to an increased life expectancy in the elderly population (1-4). Degenerative aortic stenosis (AS) is associated with a high mortality if diagnosed late and if no valve replacement therapy is performed (5). In patients with an established diagnosis of AS however, only two-thirds of those meeting guideline recommendations for valve replacement therapy actually receive treatment, with failure to intervene due mostly to an overestimation of the risks involved, underestimation of symptoms or misclassification of the severity of stenosis (6,7). Recent data shows that most patients are only diagnosed when they develop symptoms, as this precipitates referral of the patient for echocardiography (8). Valve replacement therapy may have been indicated in a subset of these patients even before the onset of symptoms, not only in those with impaired left ventricular ejection fraction (LVEF <50%) or in those whom exercise testing unmasks symptoms but also in those with very severe AS (Vmax >5.5 m/s), severe valve calcification and evidence of fast progression, pulmonary hypertension or markedly elevated brain natriuretic peptide (BNP) levels (9). Furthermore, there is accumulating evidence for the clinical benefit of early intervention in all patients with asymptomatic severe AS (10,11) as symptom-onset may well represent an arbitrary timepoint in the course of the disease (12). Certainly, outcomes deteriorate in proportion to myocardial response, particularly where there is replacement fibrosis, and recovery is sub-optimal in these patients (13). As AS follows a long indolent course over years during which patients are unaware of their condition and mortality rates increase dramatically soon after onset of symptoms, both patient and physician awareness need to be increased and methods of early diagnosis rates and referral need to be improved (14). The first presentation of AS is frequently in the primary care setting and, as a result, family physicians/general practitioners (GPs) play a key role in timely diagnosis and referral of patients with suspected VHD (15). The following article tries to evaluate the status and future perspectives of patient screening for AS