Valvular heart disease
Meta-Analysis of Prognostic Value of Stress Testing in Patients With Asymptomatic Severe Aortic Stenosis

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The management strategy in asymptomatic patients with severe aortic stenosis (AS) is controversial. Aortic valve replacement has significant morbidity and mortality, while there is a risk for sudden cardiac death with conservative management. There is no consensus on the prognostic value of stress testing to stratify management. A pooled analysis of studies in patients with severe AS was performed to assess the prognostic value of stress testing for adverse events, including angina, dyspnea, acute heart failure, sudden death, and symptoms requiring aortic valve replacement. A search of published research was performed using the terms “stress test” and “asymptomatic aortic stenosis.” A random-effects model was used to calculate pooled odds ratios and 95% confidence intervals. Data from 7 studies were included (491 patients with asymptomatic severe AS). None of the patients experienced any complications during or after stress testing. There were no sudden deaths in the patients with normal stress test results after 1 year of follow-up, while 5% with abnormal stress test results had sudden cardiac death. Overall, 52 of 253 patients (21%) with normal stress test results had adverse cardiac events, compared with 156 of 238 (66%) with abnormal stress test results (odds ratio 0.12, 95% confidence interval 0.07 to 0.21, p <0.001). In conclusion, stress testing in asymptomatic patients with severe AS is safe and identifies patients at risk for adverse cardiac events and sudden cardiac death. These data suggest that stress tests can be used for risk stratification and for deciding on the timing of aortic valve replacement in asymptomatic patients with severe AS.

Section snippets

Methods

We conducted a pooled analysis of clinical studies of patients with asymptomatic severe AS who underwent stress testing and in whom outcomes data on cardiac events and referral for AVR were available. Ovid/Medline was used to identify published clinical studies from 1985 through July 2008. Key words used to search included “asymptomatic aortic stenosis” and “stress test” (Figure 1). The search yielded 59 published human clinical studies. The search was further limited to the English language (n

Results

Table 1 lists the study designs, definitions of clinical end points, observed populations, sample sizes, follow-up periods, types of stress testing, and stress protocols used. In particular, there were no differences in age distribution, with a narrow range from 50 to 66 years. However, there was some difference in the follow-up periods, ranging from 11 to 36 months. Three studies used graded bicycle ergomtery,2, 5, 6 while 3 studies used treadmill testing (modified Bruce,4 Ellestad,3 and

Discussion

The most important findings of our meta-analysis are that (1) symptom-limited stress testing is safe in asymptomatic patients with severe AS, (2) normal stress test results predict reduced risk for adverse cardiac events compared to abnormal findings, and (3) no patient with normal stress test results experienced sudden cardiac death. Our analysis consisted of 491 patients with asymptomatic severe AS, in whom there were 9 sudden cardiac deaths and 208 cardiac events. Normal stress test results

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